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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 11/05/2021
Date Signed: 11/05/2021 04:42:49 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: 82DATE:
11/05/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Ian PhitsanoukanhTIME COMPLETED:
04:50 PM
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On 11/5/21 2:20pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit on recent incident reports of falls. LPA spoke with Administrator Morgan Whinery via phone and explained the purpose of the visit. Morgan was unable to be present and gave permission for Ian Phitsanoukanh, resident care coordinator to accompany LPA and sign in her absence. LPA toured facility with Ian to ensure Title 22 compliance and safety. All sharp objects and toxins were secured. Memory care door was functioning properly including alarm device. Room temperature was 75*F throughout facility. There were no obstructions to fire exit noted. There are 5 caregivers and 2 med techs for AM shift, 4 caregivers and 2 med tech for PM shift, and 2 med tech/caregiver are scheduled for noc shift with on-call available.

LPA reviewed fall incident reports and resident files for Resident1 (R1), R2, R3, R4, R5, an R6. Falls were reported between the dates of 9-25-21 and 10-14-21. LPA also interviewed Administrator, and Ian Phitsanoukanh. Of the 6 resident falls reviewed, 4 were unwitnessed falls. All reporting requirements for incident reports received were met per regulations. Based on interviews, it was determined that facility has now implemented a fall prevention program as of 9-25-21 which includes safety protocols and in-service training. LPA reviewed fall prevention program. Fall prevention training was noted to occur on 10-28-21. Needs and service plans for R1, R2, R3, R4, R5, and R6 were reviewed by LPA. LPA observed resident rooms with fall preventions in place.

As a result of this visit, no deficiencies are cited. An exit interview was conducted with Ian Phitsanoukanh and a copy of this report was left with Ian.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
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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