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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 09/13/2021
Date Signed: 09/13/2021 04:29:18 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:A1 DEL MONTE STOCKTONFACILITY NUMBER:
392700993
ADMINISTRATOR:SAINI, ANURADHAFACILITY TYPE:
740
ADDRESS:517 E. FULTON STREETTELEPHONE:
(209) 910-5910
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:158CENSUS: 56DATE:
09/13/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:48 PM
MET WITH:Morgan WhineryTIME COMPLETED:
04:35 PM
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On 9/13/21 at 2:48pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management regarding an incident discussion with Administrator from 9/10/21. LPA met with Administrator (ADM) Morgan Whinery and explained the purpose of the visit. Incident involved Resident1 (R1) obtaining and recording temperatures for visitors upon entry. LPA interviewed Administrator and reviewed Provider Information Notice (PIN) 21-40 stating that a designated staff member shall be responsible for screening visitors upon entry. Upon entry today, LPA was greeted by R1 who took temperature upon observation. LPA observed temperature was written and recorded by designated staff member (Staff1) (S1). Administrator stated that designated staff members are now in place to verify and record all temperatures and perform screening questions for visitors upon entry. LPA observed S1 recording and verifying temperature and asking appropriate screening questions after temperature was taken by R1. LPA also interviewed R1 during today's visit. LPA also toured facility inside and out. Facility temperature was 75*F. Staffing levels were appropriate to meet resident needs. No safety hazards observed during today's visit.

Based on today's visit an advisory note LIC 9102 was created and furnished to Administrator to reflect PIN 21-40 and Title 22 regulations, Division 8. No deficiencies observed during today's visit. LPA requested updated COVID Mitigation Plan to reflect the above procedure in place for visitor screening.

An exit interview was conducted with Administrator Morgan Whinery and a copy of this report was left with Morgan.


SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
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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