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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 10/03/2023
Date Signed: 10/03/2023 02:59:33 PM


Document Has Been Signed on 10/03/2023 02:59 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: DATE:
10/03/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Anu Saini, AdministratorTIME COMPLETED:
12:00 PM
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On 10/03/23, Licensing Program Analyst, (LPA) Renee Campbell made an unannounced quarterly case management visit to this facility. Upon arrival the LPA identified herself and the purpose of the visit and met with Daisy Aguilar, Memory Care Coordinator and Anu Saini, Administrator. The focus of today's visit was to review the following:

Licensee agreed to do the following in order to bring the facility into compliance:
1. Monthly and Weekly training for staff will continue
2. Administrator will continue to be present at facility 40 hrs a week.
3. LIC 500 Staff Schedule will be provided to LPA by 08/11/23.
4. As stated by the administrator, 100 percent of all residents care plans will be updated and completed by 09/01/23.
5. Dementia residents will have updated 602’s within 2 weeks by 08/11/23.
6. A licensed architect will be engaged for the construction work with a plan to submit building permits by mid August 2023. Facility administrator to provide a copy of permits to CCL once obtained.
7. Licensee will continue to communicate with Management Company weekly.
8. Staff will receive yearly and additional dementia ongoing training as required.

LPA was provided with the current staff schedule, with shifts, and coverage upon request and resident roster. LPA Campbell requested and received the LIC500 verifying Administrators 40 hour a week schedule and LIC602’s and Needs and Service Plans for 5 residents that were randomly selected from the resident roster for review. LPA observed the facility training binder for weekly and monthly training. The facility agreed to provide yearly and weekly training schedules for future quarterly visits. The administrator emailed information regarding the architect retained by the facility. Administrator verified weekly meetings with co-licensee.
Exit interview conducted and report given.
SUPERVISOR'S NAME: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
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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