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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700997
Report Date: 09/09/2022
Date Signed: 09/09/2022 05:33:25 PM

Document Has Been Signed on 09/09/2022 05:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CAMLU ASSISTED LIVINGFACILITY NUMBER:
392700997
ADMINISTRATOR:DIANE WRIGHTFACILITY TYPE:
740
ADDRESS:6037 N. PERSHING AVENUETELEPHONE:
(209) 951-2030
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 160CENSUS: 52DATE:
09/09/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jaenine GaonaTIME COMPLETED:
05:30 PM
NARRATIVE
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On 9/9/22 Licensing Program Analyst (Maja) Jensen arrived at the facility unannounced to conduct health and safety checks. LPA Jensen met Resident Care Director Jaenine Gaona and explained the purpose of today's visit.

LPA Jensen arrived at the facility due to receiving a phone call related to concerns with the temperature in the facility. LPA Jensen toured the facility including kitchen, dining room, hallways and 4 resident rooms on the upper level. The temperature on the lower lever measured between 84 and 85 degrees.

The temperature in the hallways and resident rooms on the upper level was measured at range between 87 degrees and 97 degrees which falls outside of the regulatory range of 68-85 degrees.

A deficiency is being cited today from the California Code of Regulations, Title 22, Division 6.

An exit interview was conducted and a copy of this report along with appeal rights was given to Jaenine Gaona.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/09/2022 05:33 PM - It Cannot Be Edited


Created By: Maja Jensen On 09/09/2022 at 05:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CAMLU ASSISTED LIVING
FACILITY NUMBER: 392700997

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/10/2022
Section Cited
CCR
87303(b)(2)

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The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. This requirement was not as evidenced by:
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Licensee made adjustments to a portable air conditioner unit in the room of a resident on the second floor during the course of the visit which lowered the temperature by 4 degrees within 30 minutes and the room continues to cool. Licensee agrees to add a hydration table to the hallway of the second floor by 7pm on 9/9/22. Maintenance will add two floor blowers to second floor and email or text temperature readings to LPA by 9/10/22. Staff will check on residents on the upper floor every two hours over the course of the 24 hours.
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Based on LPAs temperature readings of the upstairs hallway and 3 resident rooms that were above 85 degrees. This poses an immediate safety, health and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022


LIC809 (FAS) - (06/04)
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