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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 11/30/2023
Date Signed: 11/30/2023 02:57:30 PM


Document Has Been Signed on 11/30/2023 02:57 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:
11/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:16 AM
MET WITH:Anu Saini and Megan MooreTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez arrived at this facility unannounced on 11/30/2023 at 11:16 AM to conduct a case management visit. LPA met with Anu Saini and Megan Moore 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 facility. It was learned resident 1 (R1) and resident 2 (R2) are not able to leave the facility unattended. Facility staff (S1) did not attempt to redirect R1 and R2 back into the facility. Moreover, (S1) reported they did not see R3 leave the building. S1 also reported they could did not advise facility med-tech or any other care staff that R1 and R2 left the facility unattended. During this outing, R1 purchased a car, and resident 2 (R2) and resident 3 (R3) returned to the facility intoxicate. As a result, the facility did not follow R1 and R2's LIC 602 Health Certification Plan.

In addition, the facility also did not complete a proper assessment regarding R1's care needs and on the ability of leaving the facility unassisted. R1's initial LIC 602 Physician Report form dated 10/09/2023 was incomplete. Section:14-K of the LIC 602 Physician Report form was left blank. Therefore, the facility indicated on the LIC 624 Unusual Incident/Injury Report that R1 was not able to leave the facility unattended. It was learned the facility updated R1's LIC 602 Physician Report form after R1 left the facility on 10/25/2023. The LIC 602 Physician Report dated 11/13/2023 indicates R1 is able to leave the facility unassisted. Additionally, it was learned R1 is not able to drive a care. At this time, it is unknown where R1's car is located. Moreover, the facility has not implemented a health and safety plan in regards to R1's ability to drive a car. Based on the information provided the facility has not conduct proper assessments for R1.

Moreover, R2's LIC 602 Physician Report states they are not able to leave the facility unassisted. According to S1, they were unaware of R2 leaving the building. It was determined the facility did not implement a plan to keep R2 safe and to provide proper care assistance when R2 is out of the facility. The following deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. An exit interview conducted and appeal rights given.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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 11/30/2023 02:57 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 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: 11/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/04/2023
Section Cited
HSC
1569.312(e)

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1569.312 (e) Basic services requirements: Every facility required to be licensed under this chapter shall provide at least the following basic services: Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being.
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Facility staff agrees to conduct elopement training for all staff by POC date 12/04/2023. Facility staff agrees to email training documents to LPA Martinez by POC date 12/04/23 5:00PM
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This requirement was not met as evidence by: based on file reviews and interviews, the Licensee did not ensure monitor the safety of R1 and R2 as they both left the facility unassisted & R1 purchased a car/ R2 return to the facility Intoxicated. This posed an immediate health & safety risk to residents.
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Type B
12/08/2023
Section Cited
CCR87463(a)

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87463(a) Reappraisals The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changesin the resident's physical, medical, mental, and social condition. This requirment was not met
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Facility staff agrees to conduct reassessments for R1 and R2 by POC date 12/08/2023. Facility staff agrees to email LPA Martinez reassessments by POC date 12/08/23 5:00 PM
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as evidence by: Based on file reviews and interviews, the Licensee did not ensure reappraisals were being conducted when R1 had a change in condition in regards to physical, medical, mental, and social condition. This posed a potential health and safety risk to R1.
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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: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
LIC809 (FAS) - (06/04)
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