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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 12/21/2021
Date Signed: 12/21/2021 03:37:56 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: 96DATE:
12/21/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Jenna SilvaTIME COMPLETED:
03:41 PM
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On 12/21/21 at 1:05pm, Licensing Program Analyst (LPA) arrived unannounced to conduct a case management visit regarding recent incident reports received. LPA met with Regional Center Executive (RCE) Jenna Silva and explained the purpose of the visit. Administrator Anuradha Saini was notified by phone and gave permission for Jenna to accommodate LPA and sign paperwork in her absence. LPA reviewed incident reports from 12-10-21 to 12/21/21. LPA also interviewed RCE. Based on record reviews and interviews, it was determined that facility reported multiple falls and other resident events between the dates noted above. Record review determined incidents were reported timely and appropriately. LPA also reviewed charts for Resident1 (R1), R2, R3, R4, and R5. Charts reviewed contained updated appraisal needs and service plans. Facility was toured with RCE. No obstructions to fire exits noted. Facility temperature was 72*F throughout. LPA did not observe any toxins or dangerous items accessible to residents in care. Based on interview, it was determined facility is utilizing an outside service to assist with additional needs of residents as necessary at this time. LPA also reviewed staffing scheduled which shows 4 staff on duty at night, 6 staff on PM, and 8 staff on AM.

Based on interviews and record reviews, no deficiencies are cited for today's visit. An exit interview was conducted with Jenna Silva and a copy of this report was left with Jenna.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
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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