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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700527
Report Date: 02/02/2024
Date Signed: 02/02/2024 09:33:50 AM

Unfounded


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
11/20/2023 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231120085129
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:
02/02/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Daisy Aguilar TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not provide adequate food service which resulted in resident’s death from malnutrition.
INVESTIGATION FINDINGS:
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On 02-02-2024 at 9:00 AM, Licensing Program Analysts (LPA) Avelina Martinez conducted an unannounced facility visit to deliver complaint findings. LPA Martinez met with Daisy Aguilar and explained the purpose of today's visit.

Throughout the course of the investigation, LPA Martinez reviewed medical notes and facility records. In addition, LPA Martinez conducted interviews. It was learned resident 1's (R1) death was not a result of malnutrition. It was learned on average R1's consumed 25-75 % of their meals. Also, R1 would refuse food if they did not like what was being served. The facility would provide alternative meals to R1. Moreover, R1 was receiving hospice services, and hospice staff would conduct visits approximately every two weeks. Hospice notes indicated no issues with malnutrition prior to R1's death. Hospice notes dated September 21, 2023 reported no environmental or safety concerns and no new health concerns. R1 passed away on September 24, 2023 due to other causes. Continued...
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
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 2
Control Number 27-AS-20231120085129
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: 02/02/2024
NARRATIVE
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This agency has investigated the complaint alleging (Staff did not provide adequate food service which resulted in resident’s death from malnutrition). We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

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: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2