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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700527
Report Date: 12/15/2023
Date Signed: 12/15/2023 03:05:33 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/17/2023 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231117144447
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: 61DATE:
12/15/2023
UNANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:Daisy AguilarTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff did not dispense medication according to doctor’s orders.
Staff changed resident’s pharmacy without authorization.
INVESTIGATION FINDINGS:
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On 12-15-2023 at 11:30 AM, Licensing Program Analysts (LPA) Avelina Martinez conducted an unannounced facility visit to follow up on a complaint investigation with the above allegations. LPA Martinez met with Daisy Aguilar and explained the purpose of today's visit.

During today's visit, LPA Martinez conducted file reviews and conducted interviews. LPA Martinez reviewed resident 1 (R1) August 2023 medication administration records (MAR). The August 2023 MAR was not fully completed. The August 2023 MAR administration entries (08/20/23-8/31/23) for medication Furosemide 40 Mg Tabs Take 1 tab by mouth daily are left blank. Additionally, on August 30, 2023, R1 was out of Sodium Chloride and not administered on this day. LPA Martinez was provided September and October MARs, however, the records did include a year. As a result, it is unknown if medications were administered in September and October of 2023.

Continued...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20231117144447
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/15/2023
NARRATIVE
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The investigation also revealed the facility did not complete a consent form to change R1's pharmacy. An emergency refill for Lasix was requested at BJRX pharmacy on July 14, 2023. Also, the facility ordered ten medications from BJRX in October of 2023. Due to R1's health insurance plan, BJRX is not an approved pharmacy. R1 received a bill in the amount of $124.84 for medications. Facility staff reported BJRX pharmacy completed a courtesy write off for the amount of $124.84 due to not having a pharmacy consent form on file. Based on the documents obtained during the investigation, the facility did not accord R1 the right to choose their own pharmacy.

As a result of this investigation, the Department finds these allegations to be Substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.

An exit interview was conducted, and a copy of this 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: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 27-AS-20231117144447
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2023
Section Cited
CCR
87468.2(a)(18)
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87468.2(a)(18) Additional Personal Rights of Residents in Privately Operated Facilities: n addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
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Facility staff agrees to conduct a personal rights and incidental and medical in-service training for Med-techs by POC date 12/29/2023. Training documents should be emailed to LPA Martinez by POC date 12/29/23 by 5 PM.
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To select their own physicians, pharmacies...This requirement was not met as evidence by: based on file review, and interviews, the Licensee did not ensure staff completed a pharmacy consent form to switch R1's pharmacy. This posed a potential health and safety risk to R1.
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Type B
12/29/2023
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical and Dental Care:A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by: Based on file review and interviews, the
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Facility staff agrees to conduct a personal rights and incidental and medical in-service training for Med-techs by POC date 12/29/2023. Training documents should be emailed to LPA Martinez by POC date 12/29/23 by 5 PM.
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Licensee did not ensure facility staff were assisting R1 with their medications as needed. 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: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3