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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 08/31/2023
Date Signed: 08/31/2023 04:07:07 PM


Document Has Been Signed on 08/31/2023 04:07 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:A1 DEL MONTE ASSISTED LIVING LODIFACILITY NUMBER:
392700527
ADMINISTRATOR:RODRIGUES, JUDYFACILITY TYPE:
740
ADDRESS:1321 S FAIRMONT AVENUETELEPHONE:
(209) 334-3436
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:145CENSUS: 63DATE:
08/31/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Daisy Aguilar, Memory Care DirectorTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Renee Campbell and LPA Victoria Brown arrived unannounced to conduct a Case Management visit on 08/31/2023 at 8:30 AM. LPA Campbell and LPA Brown arrived in the facility and observed staff working in the dining room and residents resting in the common area. LPA's Campbell and Brown met with Administrator Judy Rodrigues and Daisy Aguilar, Memory Care Director, to discuss the purpose of the visit. Community Care licensing received two incident reports dated 07/25/23 and 08/14/23 regarding Absence Without Leave (AWOL) for Resident 1(R1).

The Physician's Report (LIC602) dated 05/25/23 indicated that R1 was not able to leave the facility unassisted. During both incidents, R1 was found outside of Memory Care without assistance. During the first AWOL on 07/25/23, the facility conducted an investigation and confirmed that R1 was found outside off the premises. The incident report indicated that on 08/14/23 that R1 was found 1.5 miles from the facility. In addition it was reported that additional staff is needed in the memory care section of the facility. At this time, LPA obtained information that there is one med tech and two caregivers per shift. However, when there is a call out, there is no substitution. During interviews on 08/24/23, LPA received information that someone may have turned off the alarm and that more staff were needed in memory care. Per interviews, it was unclear how resident was able to AWOL from the facility without being observed. LPA will discuss the use of outside agencies for staffing coverage.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit.
If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Memory Care Director was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held with Memory Care Director. A copy of todays’ report provided.
SUPERVISOR'S NAME: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023
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 08/31/2023 04:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: A1 DEL MONTE ASSISTED LIVING LODI
FACILITY NUMBER: 392700527

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2023
Section Cited
CCR
87705(c)(4)

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Care of Persons with Dementia: There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by:
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Licensee shall submit a plan by POC Due date on how staffing will be addressed to ensure the safety of the residents via fax.

POC cleared prior to today's date.
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A review of submitted SIR, staff interviews and confirmation from Administrator, that R1 AWOL'd twice. This possess an immediate health and safety 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: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023
LIC809 (FAS) - (06/04)
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