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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700527
Report Date: 12/26/2023
Date Signed: 12/26/2023 05:28:13 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
09/26/2023 and conducted by Evaluator Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20230926084026
FACILITY NAME:A1 DEL MONTE ASSISTED LIVING LODIFACILITY NUMBER:
392700527
ADMINISTRATOR:RODRIGUES, JUDYFACILITY TYPE:
740
ADDRESS:1321 S FAIRMONT AVENUETELEPHONE:
(209) 334-3436
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:145CENSUS: 62DATE:
12/26/2023
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Norlynn Peterson, LVNTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Licensee is not ensuring that the facility is in conformity with Fire Marshall standards.
Facility is unsanitary
Licensee is not ensuring that facility is free from hazardous objects that pose a danger to residents in care.
INVESTIGATION FINDINGS:
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On 12/26/23, Licensing Program Analyst (LPA) Renee Campbell made an unannounced visit to the facility to deliver findings for a complaint investigation at approximately 3:30 PM. LPA Campbell met with Norlynn Peterson, Licensed Vocational Nurse (LVN) and explained the purpose of the visit.
Regarding the allegation that the licensee is not ensuring that the facility is in conformity with Fire Marshall standards, LPA Campbell reviewed photographic evidence and the report provided by the Fire Marshall and toured the facility. Photos showed equipment and miscellaneous items blocking exits and materials obstructing the sidewalk outside. Per the Lodi Fire Marshall, these items posed a hazard to the residents. 87202(a)
Regarding the allegation that the facility is unsanitary, LPA Campbell observed photographic evidence of trash and empty boxes in vacant residential rooms. The Fire Marshall also reported observing rotten fruit on the floor and seeing a hole in the floor with what appeared to be urine around it. When interviewed,
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023
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 5
Control Number 27-AS-20230926084026
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: 12/26/2023
NARRATIVE
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R1 also reported that there was “trash right outside” her patio and there were “old chairs… and furniture” outside by her room. 87303
Regarding the allegation that the licensee is not ensuring that the facility is free from hazardous objects, the Fire Marshall reported rooms with extensive “fire loading” material in room 68 “which is very dangerous”. Images were taken that showed boxes, ladders and other equipment. 87203
Based on LPA’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.
Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiency is being cited on the attached 809-D during this visit.
An exit interview was conducted, and copies of the report and appeal rights left.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20230926084026
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: 12/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/26/2023
Section Cited
CCR
87202(a)
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87202 Fire Clearance - All facilities shall maintain a fire clearance approved by … the State Fire Marshal.

This requirement is not met as evidenced by:
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POC - Facility admin has already removed items that posed a danger to residents and made rooms and common areas sanitary and has ensured conformity with fire marshall standards
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Based on observation, interviews and record reviews, the licensee did not maintain a fire clearance when exits were obstructed by trash, furniture and other items. This poses an immediate Health, Safety and Personal Rights risk to persons in care.
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Type A
12/26/2023
Section Cited
CCR
87203
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87203 Fire Safety - All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by :
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POC- All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
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Based on observation, interviews and record reviews, the licensee did not maintain facility spaces as required by the Fire Marshall.
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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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20230926084026
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: 12/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/26/2023
Section Cited
CCR
87303(a)
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87303(a) The facility shall be clean, safe, sanitary and in good repair at all times.



This requirement is not met as evidenced by:
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POC - Facility admin has already removed items that posed a danger to residents and made rooms and common areas sanitary and has ensured conformity with fire marshall standards
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Based on observation, interviews and record reviews, the licensee did not remove rotten fruit and other trash from the floors to provide a clean, safe and sanitary environment.
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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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
09/26/2023 and conducted by Evaluator Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20230926084026

FACILITY NAME:A1 DEL MONTE ASSISTED LIVING LODIFACILITY NUMBER:
392700527
ADMINISTRATOR:RODRIGUES, JUDYFACILITY TYPE:
740
ADDRESS:1321 S FAIRMONT AVENUETELEPHONE:
(209) 334-3436
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:145CENSUS: 62DATE:
12/26/2023
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Norlynn Peterson, LVNTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Uncleared adults have access to residents in care.
INVESTIGATION FINDINGS:
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On 12/26/23, Licensing Program Analyst (LPA) Renee Campbell made an unannounced visit to the facility to deliver findings for a complaint investigation at approximately 3:30 PM. LPA Campbell met with Norlynn Peterson, LVN and explained the purpose of the visit.
Regarding the allegation that uncleared adults have access to residents in care, LPA Renee Campbell attempted to verify staff during the visit to the facility. After a list of staff were printed out from the LIC 501, any staff LPA Campbell encountered were verified from the staff list. LPA Campbell found no staff who were not cleared.
Based on all the information collected by the Department there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore this allegation is unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, no deficiencies cited. Exit interview was held and a copy of report was given to Norlynn Peterson, LVN
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5