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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700527
Report Date: 02/29/2024
Date Signed: 02/29/2024 01:17:14 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
01/05/2024 and conducted by Evaluator Liza King
COMPLAINT CONTROL NUMBER: 27-AS-20240105135347
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: DATE:
02/29/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Judy Rodriguez, AdminTIME COMPLETED:
11:03 AM
ALLEGATION(S):
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Facility staff is not performing residents glucose testing as ordered.
Staff mismanaged resident's medications.
Facility is in disrepair.
INVESTIGATION FINDINGS:
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LPM, Liza King and LPA Avelina Martinez arrived at facility to follow up on a complaint investigation. LPM was met by Administrator Judy Rodriguez and the purpose of the visit was discussed.
LPM was provided the July MAR for R1, no other MARS were available for this client. Medications were not documented as provided during the AM shift for 9 days and 2 days on PM shift. In addition, monitoring of the residents blood glucose was not being conducted on a consistant basis. Administrator present during todays visit visually inspected the MARs and is aware of the deficiency.
Additionally a tour of the Memory Care area had a strong odor of urine. Interview with Assistanrt Administrator confirmed that the current carpet cleaner is unable to address the odor of the area and staff are aware and are looking into a commercial cleaner or renting a carpet cleaning machine.
As a result of this investigation, the Department finds these allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is 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 the 9099 report, LIC 9099-D, and appeal rights were given to the facility.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
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-20240105135347
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: 02/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/29/2024
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental: (4) The licensee shall assist residents with self-administered medications as needed.This was not met as evidenced by:
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The Admin agreed to have a Director conduct MAR audits weekly. Documentation of audits will be maintained at facility and availabble upon request. A copy of the most recent audit will be provided by eod 03/02/2024.
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review of the MARs for R1 showed monitoring of the residents blood glucose was not being conducted on a consistant basis and Medications were not documented as provided during the AM shift for 9 days and 2 days on PM shift. This is an immediate Health and Safety risk for residents in care.
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Type B
02/29/2024
Section Cited
CCR
87625(b)(3)
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(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This was not met as evidenced by:
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The Admin will have the carpets cleaned either professionally or use a commercial cleaner by March 31, 2024. A POC visit will be conducted to verify.
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During todays observation the Memory care area had anodor of urine. This poses a potential health and safet risk to clients in care.
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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: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2