392700527-4-8-2024-27-AS-LKIG-D4CVK2-20240415162938

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700527
Report Date: 04/08/2024
Date Signed: 04/08/2024 01:09:34 PM

Unsubstantiated

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 Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240105135347

FACILITY NAME:	A1 DEL MONTE ASSISTED LIVING LODI		FACILITY NUMBER:	392700527
ADMINISTRATOR:	SAINI, ANURADHA		FACILITY TYPE:	740
ADDRESS:	1321 S FAIRMONT AVENUE		TELEPHONE:	(209) 334-3436
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	145	CENSUS: 64	DATE:	04/08/2024
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Judy Rodriguez and Stephen Ratlift		TIME COMPLETED:	01:07 PM

ALLEGATION(S):

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Facility did not safeguard resident's personal property.
Staff are not following the modified diet prescribed for resident.
Facility staff did not communicate with resident's POA.

INVESTIGATION FINDINGS:

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On 04/08/2024 at 8:30 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA Martinez met with Judy Rodriguez and Stephen Ratlift during today’s visit and explained the purpose of today's visit.

Throughout the course of this investigation, LPA Martinez conducted interviews and reviewed facility records and conducted facility inspections. During the file review, it was learned the facility did not complete a LIC 621 Client/resident personal property and valuables form. In addition, LIC 602 Physician report dated September 15, 2022 is incomplete, and section 17 Ambulatory status is not completed. Moreover, Preplacement Appraisal information dated November 01, 2022 indicated resident 1 (R1) is ambulatory, and states R1 did not use a wheelchair. This document was also signed by R1's authorized representative. Also, there is no documentation stating R1 had a wheelchair or being lost. As a result, there is not enough evidence to prove the facility did not safe guard R1's personal property.
Continued...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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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
	VISIT DATE: 04/08/2024

NARRATIVE

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LPA Martinez reviewed R1's physician report LIC 602 dated September 15, 2022. The LIC 602 Physician Reported indicated R1 was on a NAS diet, regular texture, and thin liquids. The facility had no record of any incidents where R1 was not provided a NAS diet. Additionally, R1's file contained communication documentation between the facility and R1's physician. LPA Martinez also reviewed other documentation that was provided during complaint investigation. The documentation provided was is in word format, which did not contain substantial evidence to prove that facility staff were not communicating with R1's POA.

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 violations did or did not occur, and therefore the allegations are unsubstantiated.

An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024

LIC9099 (FAS) - (06/04)

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