392700993-9-8-2021-27-AS-KHOS-C6VLFG-20210915084308

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700993
Report Date: 09/08/2021
Date Signed: 09/08/2021 03:55:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/09/2021 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20210809164015

FACILITY NAME:	A1 DEL MONTE STOCKTON		FACILITY NUMBER:	392700993
ADMINISTRATOR:	SAINI, ANURADHA		FACILITY TYPE:	740
ADDRESS:	517 E. FULTON STREET		TELEPHONE:	(209) 910-5910
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95204
CAPACITY:	158	CENSUS: 54	DATE:	09/08/2021
		UNANNOUNCED	TIME BEGAN:	02:46 PM
MET WITH:	Morgan Whinery		TIME COMPLETED:	03:55 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not provide lift assist to resident
Residents were left unattended

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 9-8-21 at 2:46pm Licensing Program Analyst (LPA) Michael Bilger arrived at facility unannounced to deliver findings for the complaint allegations listed above. LPA met with Administrator Morgan Whinery and explained the purpose of the visit. During the course of this investigation LPA conducted interviews with 3 residents, 4 staff members, and fire department personnel. LPA also reviewed facility file documentation including staffing roster, resident roster, actual hours worked for 8-6-21 to 8-7-21, physician report, needs and service plan, incident report, facility 9-1-1 protocol, and staff training records.
Allegation #1: Facility staff did not provide lift assist: LPA conducted interviews with Resident(1) (R1), R2 and R3, and reviewed actual hours worked for the period of 8-6-21 to 8-7-21 as well as incident report. LPA also interviewed Staff3 (S3) and S4. A review of actual hours worked determined that 2 staff members were on duty during two 9-1-1 calls at 1:26am and 3:08am. Based on interviews and record reviews it was determined that 9-1-1 personnel was contacted by R2 at 1:26am due to R2’s observation of R1 sliding out of wheelchair and unsuccessful attempts to locate staff on duty; R1 did not utilize alert system and was heard by R2 requesting assistance which prompted the 9-1-1 call by R2. {Cont. on 9099C}

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021

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 3

Control Number 27-AS-20210809164015

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 STOCKTON	FACILITY NUMBER: 392700993
	VISIT DATE: 09/08/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on interview with fire department personnel who arrived on scene after the 1:26am call, it was determined that R1 was observed to be in a slouching position and needed to be lifted and repositioned in his wheelchair to prevent a fall. Based on interview with R1 and fire department personnel, it was determined that although fire personnel and two staff were in his room at the time, only the fire department personnel provided the necessary lift and repositioning assistance. Additional interview with S3 revealed that staff has previously provided repositioning assistance for resident. A record review of training for activities of daily living (ADL) and transfers revealed that training occurred on 7/1/21 for Staff1 (1) and 1/7/21 for S2. S2 additionally received training on care and supervision on 3/22/21. Based on interviews and record reviews, the preponderance of evidence standard is met, therefore this allegation is determined to be SUBSTANTIATED.

Allegation #2: Resident’s were left unattended: LPA conducted interviews with R1, R2, and R3 and reviewed actual hours worked for the period of 8-6-21 to 8-7-21 as well as incident report. Additional interview was conducted with fire department personnel. A review of actual hours worked determined that 2 staff members were on duty during two 9-1-1 calls at 1:26am and 3:08am. Based on interview with fire department personnel it was determined that during the 9-1-1 call visit at 1:26am and 3:08am, the 2 staff members on duty were accompanying fire department personnel in the assisted living section of the facility assisting R1. An interview with R2 revealed that both staff members were seen with fire department personnel in the assisted living section. An interview with R1 revealed that three individuals, one of whom was the fire department personnel were in his room on the assisted living section. Additional interviews with S3 and S4 revealed that a need for additional assistance was not requested during the times of the 9-1-1 calls. Based on interviews and record reviews it is determined that only 2 staff members were on duty during the 9-1-1 calls and while accompanying fire department personnel, left the memory care section of the building unattended. As a result, the preponderance of evidence standard has been met and this allegation is SUBSTANTIATED

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

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 27-AS-20210809164015

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 STOCKTON	FACILITY NUMBER: 392700993
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/08/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/09/2021 Section Cited CCR 87413(a)(1)	1 2 3 4 5 6 7	Section 87413 Personnel-Operations (a) In each facility (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit a staffing plan to ensure residents are not left unattended by staffing personnel. Licensee will submit a staffing schedule ensuring adequate coverage to prevent lack of supervision of residents. Licensee to submit above POCs by due date.
	8 9 10 11 12 13 14	Based on interviews and record review, One staff member was attending to memory care unit and left unit unattended. Licensee did not ensure qualified personnel coverage in the memory care unit when staff member left memory care unit unattended which poses an immediate health, safety, and resident rights risk to residents in care.	8 9 10 11 12 13 14
Type B 09/17/2021 Section Cited CCR 80078(a)	1 2 3 4 5 6 7	80078 Responsibility for Providing Care and Supervision (a) The Licensee shall provide care and supervision as necessary to meet the client’s needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will conduct staff training on lifting and repositioning procedures and submit proof of training to LPA by POC due date. Licensee will conduct staff training on 9-1-1 emergency protocols with emphasis on when to call 9-1-1 versus performing care procedures necessary for fall prevention.
	8 9 10 11 12 13 14	Based on interviews and record reviews licensee did not ensure R1 received appropriate repositioning and lifting by staff on duty for purposes of promoting fall prevention. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3