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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 09/23/2026
Date Signed: 09/23/2026 03:30:36 PM

Document Has Been Signed on 09/23/2026 03:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 STOCKTONFACILITY NUMBER:
392700993
ADMINISTRATOR/
DIRECTOR:		SANDEEP SAINIFACILITY TYPE:
740
ADDRESS:517 E. FULTON STREETTELEPHONE:
(209) 910-5910
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 158CENSUS: 147DATE:
09/23/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Rheema BhallaTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 09/23/2026, Licensing Program Analyst (LPA) Kimberly Kulich conducted an unannounced case management at A1 Del Monte Assisted and Memory Care. LPA was greeted by VP of Operations Neil Metha (NM) and Rhemma Bhalla (RM). LPA introduced that the reason for today's visit was to investigate and gather information regarding a report of elder abuse that occurred on 09/17/2026 at 4:30PM.
LPA requested documents:

1. Mandatory State Licensing (LIC) Forms
· LIC 624 / 624A (Unusual Incident/Injury Report): The official report submitted to the CDSS CCLD within 7 days of the incident. Review Box 3 and Box 4 for specific timeline descriptions.
· LIC 603 / 603A (Individual Resident Appraisal): The multi-page assessment tracking the resident's physical capabilities, mobility limitations, and necessary transfer assistance under § 87463.
· LIC 602A (Physician's Report): The most recent official medical report completed by the primary physician. Verify Section V for cognitive diagnoses (Dementia/Alzheimer's) and ambulatory limitations under § 87458.
· LIC 622 (Centrally Stored Medication Record): The Medication Administration Record (MAR) tracking all scheduled and PRN (as-needed) medications given within 48 hours prior to the fall under § 87465.
· LIC 500 (Personnel Report): The official master facility staffing roster used to cross-reference authorized personnel active on the day of the incident.
· LIC 501 (Personnel Record): Personnel files for the specific staff member(s) assigned to the resident's unit at 7:00 AM, verifying background clearance under § 87411.
Lisa Rios
Kimberly Kulich
DATE: 09/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 STOCKTON
FACILITY NUMBER: 392700993
VISIT DATE: 09/23/2026
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LIC 311F (Staff Training Logs): Verification logs proving the assigned caregivers completed their mandatory 40-hour initial and annual training on fall prevention and dementia care under § 87411.5.
· LIC 9020 (Register of Facility Residents): The official census log to verify the exact building occupancy on that day to evaluate staffing-to-resident ratios under § 87415.

2. Internal Facility & Operational Logs
· Individualized Support Plan (ISP): The facility's internal actionable blueprint detailing whether the resident required 'Standby Assistance', '1-Person Physical Assist', or 'Total Dependability' for bathing/showering under § 87467.
· Caregiver Daily Shift Notes & Progress Logs: All written or electronic entries from the night and morning shifts immediately surrounding the 7:00 AM fall. Look for indications of unassisted wandering or early morning confusion.
· Electronic Biometric / Timecard Records: Actual digital punch-in/punch-out records for all scheduled caregivers between 6:30 AM and 7:30 AM to audit for shift-change coverage caps or understaffing under § 87415.
· Internal Incident Log / QA Review: The initial unedited internal report filled out by the responding med-tech or caregiver immediately following the fall prior to executive review.
· Facility Maintenance and Work Order Logs: The preceding 30 days of maintenance requests for the specific bathroom/shower area, focusing on call cords, loose grab bars, lighting replacements, or floor resurfacing.

Interviews and staff statements recorded in LIC 812's

Based on inspection of facility, the facility falls within the Title 22 requirements and no citations were issued today.

Based on documentation reviewed including statements of the occurrence from the complainant, staff involved statements, character attestations for staff members and interviews with staff and residents during this case management, further investigation is required.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Kimberly Kulich
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2026
LIC809 (FAS) - (06/04)
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