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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 01/08/2024
Date Signed: 01/08/2024 01:18:16 PM


Document Has Been Signed on 01/08/2024 01:18 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: 60DATE:
01/08/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:44 AM
MET WITH:Daisy Aguilar and Judy Rodriguez and Stephen RatliftTIME COMPLETED:
02:00 PM
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On 01/08/2024, Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a plan of correction (POC) visit. LPA met with Daisy Aguilar and Judy Rodriguez and Stephen Ratlift and explained the purpose of the visit.

Today's visit is in regards to citations issued on January 04, 2024. LPA Martinez observed the following deficiencies to be corrected by the Plan of Correction date.

1. Large glass window leaning up against residents patio's fence. Assisted Living (AL).

2. Exterior water heater storage room door is not in good repair (Door latch/lock is broken, as a result, storage door is open and water heater wires are exposed and made assessable to residents in care). AL side

3. Fence boards missing creating an unsafe and unsecured perimeter at the memory care resident exterior patio. Memory Care (MC)


4. Dementia unit interior exit door is not in good repair. This door opens to the exterior residents' patio and leads to the direct pathway of the exterior egress door. MC
5. Reassessments
6. maintenance and Operation
7. Personnel Requirements
8. Administrator Qualifications

Based upon 01/08/2024 inspection, LPA Martinez observed the deficiencies cited have been cleared. The Licensee complied with the terms of the plan of correction and corrected the deficiencies by plan of correction due date.

An exit interview was held, 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: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2024
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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