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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700527
Report Date: 06/20/2024
Date Signed: 06/20/2024 02:51:42 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
11/28/2023 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231128151937
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: 69DATE:
06/20/2024
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Marlene BremerTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident sustained a head injury in care due to lack of supervision.
Licensee did not ensure that resident was regularly observed for changes in physical condition.
Facility staff did not provide a written incident report to resident's responsible person.
Resident sustained a hip fracture in care due to lack of supervision.
Facility staff did not ensure resident was fed at meal times.
INVESTIGATION FINDINGS:
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On June 20, 2024 at 12:20 PM, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit to deliver complaint investigation findings. LPA Martinez met with Marlen Bremer and explained the purpose of today's visit.

Throughout the course of the investigation, the Department conducted interviews, reviewed facility documents, and reviewed hospital records. The investigation revealed resident 1 (R1) was receiving hospice services. Hospice notes dated May 18, 2023 indicated R1 was a fall risk. On May 18, 2023 hospice notes reported R1 had a fall 3 weeks prior to May 18, 2023 although there were no other notes discussing the fall. It was also noted facility staff were educated on safety and fall prevention by hospice staff. In addition, facility staff were advised to ensure R1 wore appropriate shoes due to falls. Furthermore, hospice notes indicate facility staff verbalized understanding regarding the fall plan.

Continued...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024
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 5
Control Number 27-AS-20231128151937
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: 06/20/2024
NARRATIVE
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Additionally, hospice notes dated May 28, 2023 indicated R1 had a un-witnessed fall with no injuries. May 28, 2023 hospice notes report facility staff was re-educated on safety and fall prevention. Furthermore, facility staff were advised to keep pathways clear and to check on R1 frequently. After R1 sustained the un-witnessed fall, the facility did not conduct a facility re-assessment, and the facility did not update R1's Needs and Service Plan to include a fall risk prevention plan.

On August 03, 2023, R1 was found at the laundry room. R1 was found laying on the ground, and was assessed for injuries. It is unknown how long R1 was laying on the ground, and R1 had no apparent injuries from the fall. Hospice notes indicate facility staff were re-educated on safety and falls, and facility staff verbalized understanding of fall prevention plan. After this un-witnessed fall, the facility did not reassess R1 for the falls, and did not complete a updated Needs and Service Plan.

On October 11, 2023, R1 was found at the garden lobby on the ground. R1 was found bleeding from upper left forehead. R1's upper left eye was bruised and swollen. R1 was sent to the Emergency Room. R1 was diagnosed with traumatic subdural hemorrhage, contusion on another part of head, and subdural hematoma. Hospital records report R1 sustained the un-witnessed fall from a non-moving wheelchair.

As a result, R1 sustained multiple un-witnessed falls due to lack of care and supervision from the facility. It was also determined R1 sustained serious bodily injuries from the October 11, 2023 un-witnessed fall. As R1 required emergency hospital care, and sustained a traumatic subdural hemorrhage, contusion on another part of head, and subdural hematoma. An immediate civil penalty shall be assessed on June 20, 2024; based on the fact the facility did not provide basic care services to R1, which posed an immediate threat to the Health, Safety, and Personal Rights of R1. Moreover, because you have been cited for repeating the same violation within 12 months (California Code of Regulations Section 87464(f)(1) Basic Services), a civil penalty in the amount of $1,000.00 shall be assessed on 6/20/2024. Please refer to LIC 421IM form for additional information.

Moreover, Due to R1 sustaining serious bodily injury, the violation warrants civil penalty assessments. At this time, the civil penalty assessments are under review, and a civil penalty determination is pending by the Department. Once civil penalty assessments have been determined, a LPA will return at a future date to assess the civil penalties. Continued...
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20231128151937
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: 06/20/2024
NARRATIVE
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Moreover, LPA Martinez conducted interviews, and it was learned that written reports are not provided to the residents' responsible party. It is not within facility policy to mail out written incident reports to a responsible party. Based on this information provided, the facility did not follow Title 22 reporting requirements. Title 22 reporting requirements indicates A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of an event that threatens the welfare, safety or health of any resident. Based on the evidence gathered throughout this investigation, it was learned R1 had multiple falls, and also sustained serious bodily injuries that required ER care and services. Therefore, it was determined the facility was required to provide R1's responsible party a written report due to nature of fall incidents, which also threatened the welfare and safety of R1.

because you have been cited for repeating the same violation within 12 months (California Code of Regulations Section 87211(a)(1)(D) Reporting Requirements), a civil penalty in the amount of $1,000.00 shall be assessed on 6/20/2024. Please refer to LIC 421IM form for additional information.

It was also learned R1 had multiple physical/health changes. However, the facility did not update R1's Needs and Service Plan. R1's physical/health changes included medication refusal, food consumption refusal, diet change from mechanical soft to puree, and anxious behaviors. As a result, the facility did not implement a plan that would continue to observer R1' physical and health changes, and that would continue to provide oversight/observation of: medication refusal, food consumption refusal, diet change from mechanical soft to puree, and anxious behaviors. It was determined the facility did not observe R1 for changes in condition, and a citation can be found on the 9099-D Page.

Additionally, the following allegations: "resident sustained a hip fracture in care due to lack of supervision" and "facility staff did not ensure resident was fed at meal times" were substantiated on separate complaints. As a result, the facility will not be re-cited. Please see the following complaint numbers for additional information: 27-AS-20230728105712 and 27-AS-20231220082024.

An exit interview was conducted, and a copy of this 9099 report, 9099 D-Page, appeals rights, and LIC 421IM were provided to the facility.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20231128151937
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: 06/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/21/2024
Section Cited
CCR
87466
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Observation of the Resident:The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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Facility Staff agrees to conduct training for all staff regarding observation of residents and how to report changes in condition to management by POC Date July 04, 2024 and email training documents to LPA by July 04, 2024 5PM. Facility staff agrees to email LPA training agenda by 06/21/2024 by 5:00 PM.
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This requirement was not met as evidence by: Based on observation, file review, and interviews, the Licensee did not ensure staff were observing R1 for physical/health changes. This posed an immediate health and safety risk to R1.
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Type A
06/21/2024
Section Cited
CCR
87464(f)(1)
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87464(f)(1) Basic Services: basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by: Based on observation, file review, and interviews, The Licensee did not
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Facility Staff agrees to conduct training for all staff regarding basic services by POC Date July 04, 2024 and email training documents to LPA by July 04, 2024 5PM. Facility staff agrees to email LPA training agenda by 06/21/2024 by 5:00 PM.
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ensure staff provide care and supervision to R1. Due to not providing care and supervision R1 sustained multiple falls, and sustained a serious bodily injuries, which required hospitalization. This posed an immediate health and safety risk to R1.
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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: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20231128151937
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: 06/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/21/2024
Section Cited
CCR
87211(a)(1)(D)
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87211(a)(1)(D) Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events ...
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Facility Staff agrees to conduct training for all staff regarding reporting requirements by POC Date July 04, 2024 and email training documents to LPA by July 04, 2024 5PM. Facility staff agrees to email LPA training agenda by 06/21/2024 by 5:00 PM.
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Any incident which threatens the welfare, safety or health of any resident..This requirement was not met as evidence by: based on file review and interviews, the Licensee did not ensure a written incident report was provided to R1's responsible party. This posed a potential health and safety risk to R1.
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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: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5