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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 12/09/2021
Date Signed: 12/09/2021 12:22:58 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: 95DATE:
12/09/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:12 AM
MET WITH:Jenna SilvaTIME COMPLETED:
12:35 PM
NARRATIVE
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On 12-9-21 at 12:12pm Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management relating to complaint #27-AS-20211116124932. LPA met with Jenna Silva and explained the purpose of the visit. Licensee Sunny Saini gave permission for Jenna to sign documents and accommodate LPA. During a complaint visit on 11-17-21, LPA reviewed Resident1 (R1) record and conducted interview with staff1(S1). During record review it was determined that physician’s report for R1 was not obtained and was absent from R1s chart.

As a result of today’s visit, deficiencies are cited under Title 22, Division 6, Chapter 8. An exit interview was conducted with Jenna Silva and a copy of this report was left with Jenna. Appeal rights provided.

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

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2021
Section Cited

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Client Medical Assessment. Except for licensees of ARFs, prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client…The requirement is not met as evidenced by:
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Based on record review and interview, physician’s report from R1’s chart was absent and not obtained. This poses a potential health and safety risk to residents in care.
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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: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2021
LIC809 (FAS) - (06/04)
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