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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 10/25/2023
Date Signed: 10/25/2023 10:54:34 AM


Document Has Been Signed on 10/25/2023 10:54 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:A1 DEL MONTE ASSISTED LIVING LODIFACILITY NUMBER:
392700527
ADMINISTRATOR:SAINI, ANURADHAFACILITY TYPE:
740
ADDRESS:1321 S FAIRMONT AVENUETELEPHONE:
(209) 334-3436
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:145CENSUS: 70DATE:
10/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Anu Saini and Neil Mehta and Dasiy AguliarTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Avelina Martinez arrived at this facility unannounced on 10/25/2023 at 9:00 AM to conduct a case management visit. LPA Martinez met with Anu Saini and Neil Mehta and Dasiy Aguliar and explained the purpose of the visit.

The purpose of the visit is to follow up on deficiencies learned during complaint investigation 27-AS-20230728105712. Based on the investigation the following violations were learned: administrator qualifications, inadequate staffing, and reporting requirements.

Throughout complaint investigation 27-AS-20230728105712, it was learned the facility did not have adequate care and supervision during a July 22, 2023 incident. The incident resulted in resident 1 (R1) sustaining serious bodily injury. R1 was diagnosed with an acute chronic intracranial subdural hematoma, a wrist fracture, and a humerus fracture. At the time of the incident, there were no staff present. One resident and four staff all reported there were no staff present during the July 22, 2023 incident. Furthermore, four staff reported the incident could have been prevented if the facility offered more care and supervision to residents in care. Three staff reported the facility is understaffed. It was also reported common areas do not always have a care staff assigned due to being understaffed. It was learned common areas are not supervised because staff have other duties to complete.

The complaint investigation 27-AS-20230728105712 also determined the facility does not provide the required care and supervision to residents in care. In addition, it was determined the facility is understaffed. Moreover, a citation for Administrator Qualification can be found on the 809-D Page. Due to the fact, the Administrator should provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs.

Continued...

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: A1 DEL MONTE ASSISTED LIVING LODI
FACILITY NUMBER: 392700527
VISIT DATE: 10/25/2023
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Furthermore, the LIC 624 Unusual Incident/Injury Report regarding the July 22, 2023 incident is dated July 24, 2023. The facility did not follow reporting requirements. As Any suspected physical abuse that results in serious bodily injury of an elder abuse, shall be reported to Community Care Licensing Department (CCLD) within two hours of the incident. The facility did not submit a LIC 624 Unusual Incident/Injury Report in a timely manner to CCLD.

The facility has a history of not submitting LIC 624 Unusual Incident/Injury Report to CCLD in a timely manner. A suspected abuse incident which involved two residents was not reported in a timely manner to CCLD. The incident involved a resident being slapped by another resident on October 15, 2023. The facility called local law enforcement on the date of incident, however, the LIC 624 Unusual Incident/Injury Report was submitted to the Department on October 17, 2023.

On September 30, 2023, there was an incident that involved two residents being in an altercation. One resident sustained a head injury and was sent out the Emergency Room (ER). Local law enforcement was called, and CCLD received an LIC 624 Unusual Incident/Injury Report on October 02, 2023. As a result, the facility is not following reporting requirements.



The following deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. The deficiencies can be found on the 809-D page.

An exit was interview conducted, and a copy of the 809 report, 809-D page, and appeal rights were given to the facility.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/25/2023 10:54 AM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2023
Section Cited
CCR
87411(a)

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Personnel Requirements - General 87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...This requirement was not met as evidence by: Based on file review and interviews, the Licensee did not ensure
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Facility staff reported facility has implemented 3 caregivers and 1 med-tech and 1 activities worker and 1 housekeeping worker and one memory care director in memory care unit. These employees all assist with care and supervision. In addition, a call off plan with a call back up list has
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The facility was fully staffed to meet the needs of residents in care. In particular Resident 1 and Resident 2. As they got in an altercation and R1 sustained serious bodily injuries. This posed and immediate health and safety risk to residents in care.
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been implemented. The facility is also currently hiring. Cross care and supervision training is provide to all staff during on boarding. Except Maintenance workers and vendors. Facility staff agrees to email plan to LPA Martinez by POC date 10/26/2023.
Type B
11/03/2023
Section Cited
CCR87211(2)

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87211(2) Reporting Requirements: (b) Any suspected physical abuse that results in serious bodily injury of an elder or dependent adult shall be reported to... licensing agency... within two (2) hours as required by Welfare and Institutions Code Section 15630(b)(1).This requirement was not met as
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Facility staff agrees to provide Reporting training to staff by POC date 11/03/2023. Facility staff agrees to email training documentation to LPA Martinez by POC 11/03/23 by 5 PM
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evidence by: Based on file review and interviews the Licensee did ensure staff were meeting reporting requirements and submitting LIC 624 Unusual incident reports that include elder abuse within 24 hours to CCLD. This posed a potential 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 10/25/2023 10:54 AM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2023
Section Cited
CCR
87405(h)(5)

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87405(h)(5) Administrator - Qualifications and Duties:The administrator shall have the responsibility to:Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and need...This requirement was not met as
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Facility Administrator agrees to review Administrator Qualifications and Duties regulation by POC date 10/26/2023. Administrator agrees to email LPA Martinez a statement indication regulation was reviewed by POC date 10/26/23 by 5 PM.
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evidence by:Based on file review and interviews, the Administrator did not ensure R1 and R2 was provided physical and mental well being care and supervision. As a result, R1 sustained serious bodily injury. This posed 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4