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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 11/21/2023
Date Signed: 11/21/2023 03:05:26 PM


Document Has Been Signed on 11/21/2023 03:05 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 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: 64DATE:
11/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Anu Saini TIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPAs) Avelina Martinez and Jennifer Fain arrived at this facility unannounced on 11/21/2023 at 1:00 PM to conduct a case management visit. LPAs met with Anu Saini and explained the purpose of the visit.

The purpose of the visit is to follow up on an incident report received on 11/01/2023. The report stated on 10/25/2023 at 3:00 PM, three residents left the facility to go out in the community. It was learned two residents were not able to leave the facility unattended. LPAs requested the following documentation: Health certification forms and assessments. Licensee Anu Saini reported she did not have all assessments at the facility. LPAs obtained copies of documents that were available, and LPAs will return at a later date to follow up this case management. In addition, missing assessments shall be emailed to LPA Martinez by 8:00 AM 11/22/2023. LPAs also amended a 9099 report dated 11/20/2023. Amended report was provided to Anu Saini on 11/21/2023.

An exit interview was conducted, and a copy of this 809 report was provided to the facility.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023
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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