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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700997
Report Date: 09/29/2022
Date Signed: 12/06/2022 09:07:49 AM

Document Has Been Signed on 12/06/2022 09:07 AM - 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: 49DATE:
09/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Trish Velez-Resident Care CoordinatorTIME COMPLETED:
03:30 PM
NARRATIVE
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On 9/29/22 at approximately 2:15pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management for deficiencies related to theft of a resident's funds. LPA Jensen met with resident care coordinator Trish Velez and explained the purpose of today's visit. LPA Jensen also spoke to Administrator Diane Wright over the phone and explained the purpose of today's visit.

On 9/16/22 the Administrator contacted LPA Jensen to notify her of a theft of a resident's funds by a staff member. The Administrator complied with all reporting requirements within the required time frame. The staff member was terminated. The Administrator notified law enforcement, APS and the Ombudsman. The Administrator also sent an LIC 624, LIC 9060 and completed an SOC 341A.

LPA Jensen requested staff 1's (S1's) personnel file so that the Department can seek an exclusion on the responsible party.

Deficiencies are being cited from the California Code of Regulations, Title 22, Division 6.

An exit interview was conducted and a copy of this report and appeal rights were given to the Administrator.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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 12/06/2022 09:07 AM - It Cannot Be Edited


Created By: Maja Jensen On 09/29/2022 at 09:46 AM
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: 09/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2022
Section Cited
CCR
87217(b)

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87217 Safeguards for Resident Cash, Personal Property, and Valuables
(b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. This requirement was not met as evidenced by:
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The Licensee immediately terminated the employee. The Licensee also conducted staff training on mandated reporting. The Licensee met with the family of the resident and explained all actions that have been taken. The Licensee has made a safe available for residents to keep valuables in should they choose to do so. No other victims have been identified. No further Plan of Correction is required.
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Based on the facility's self reporting, a staff member used a resident's check to deposit funds in to their own account. This poses a potential health, safety 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: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022


LIC809 (FAS) - (06/04)
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