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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700527
Report Date: 11/17/2023
Date Signed: 01/23/2024 08:17:23 AM


Document Has Been Signed on 01/23/2024 08:17 AM - 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: 70DATE:
11/17/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Anuradha SainiTIME COMPLETED:
11:00 AM
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A Non-Compliance Conference (NCC) was conducted today on November 17, 2023 via Microsoft Teams with the Sacramento South Regional Office at 10:00 AM. Present in the meeting are Licensing Program Manager Stephenie Doub, Licensing Program Manager Liza King, and Licensing Program Analyst Avelina Martinez; DHCS representatives: Andrew Chen and Sam Andy; Facility Representatives Anuradha Saini , Sunny Saini, Stephen Ratlift, Sharon Wang, and Josh Johnson.

The non-compliance conference process was explained during this meeting to include the Administrative process.

The NCC is being held as a result of complaint investigation 27-AS-20230728105712. The facility received three: A citations and one: B citation . The citations consist of the following: reporting requirements, administrator qualifications, basic services, personnel requirements,

Issues discussed during the Non-Compliance Conference were:
  1. July 28, 2023 27-AS-20230728105712 complaint.
  2. 27-AS-20230728105712 citations
  3. Under staffing concerns/Increasing staff
  4. Needs and Services Plan
  5. Activity Program in Memory Care
  6. Dementia Plan and Training
  7. Change of Ownership

Continued...
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023
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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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
VISIT DATE: 11/17/2023
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The facility has stated they will do the following to achieve continued and substantial compliance:
  • Increase staffing
  • Changed activity program Director in Memory Care
  • Continue conducting on-site random visits
  • Implemented PM shift lead position for Memory Care Unit
  • Update LIC 500 Personnel Report and provide form to CCLD
  • Provide CCLD with LVN job duty description
  • Provide CCLD a copy of the facility's Dementia Training Program
  • Provide CCLD care staff management oversight plan.
  • Hire one additional staff to provide oversight in the memory care unity and assist with preventing resident on resident altercations. New staff will be hired by December 15, 2023

Facility staff will email CCLD facility plans to achieve compliance by November 27, 2023 5:00 PM.

In addition, at this meeting the notified Licensee/Administrator was advised future non-compliance regarding the above and other regulatory components will result in additional citations, civil penalties, and further potential administrative action.

Community Care Licensing Department (CCLD) will do the following:

  • Increase Monitoring to quarterly visits.
  • TSP

Completing the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager.

Per California Code of Regulations (CCRs) - Title 22 no deficiencies are being cited during this visit. An exit interview was conducted with Saini Anuradha, and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023
LIC809 (FAS) - (06/04)
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