392700993-12-9-2021-27-AS-KHOS-C9YLQM-20211223075745

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700993
Report Date: 12/09/2021
Date Signed: 12/09/2021 12:09:03 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
11/16/2021 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20211116124932

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: 95	DATE:	12/09/2021
		UNANNOUNCED	TIME BEGAN:	10:18 AM
MET WITH:	Jenna SIlva		TIME COMPLETED:	12:04 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident had unwitnessed fall and received injuries
Reporting party not notified of fall
Reappraisal not completed for change in condition
Documents not provided to DPOA upon request

INVESTIGATION FINDINGS:

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

On 12-9-21 at 10:18am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the complaint allegations listed above. LPA met with Jenna Silva, regional executive director and explained the purpose of the visit. Licensee Sunny Saini gave permission for Jenna to sign documents and accomodate LPA. During the course of this investigation LPA reviewed facility file documentation including staffing schedule for October 2021, actual hours worked by staff on October 26-27, 2021, appraisal forms for resident1 (R1), and Incident report for R1. LPA conducted a facility observation on 11-17-21. LPA also conducted interviews with Staff1 (S1) on 1-17-21, S3 on 11-24-21, and S4 on 11-29-21. LPA also conducted interviews with R1 on 11-17-21 and interview with responsible person for R1 on 11-24-21. Based on interviews conducted, facility observation, and records reviewed the findings for the allegations are as follows:
Allegation #1: Resident had unwitnessed fall and received injuries: LPA reviewed incident report for R1 dated 10-28-21 which described a fall occurring at 5am on 10-27-21 for R1. This fall was described as an unwitnessed fall with head injury. Based on interview and observation with R1, LPA observed bruise markings on R1s face on 11-17-21. {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: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 27-AS-20211116124932

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: 12/09/2021

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

Amended from original report dated 12-9-21: Based on interview with S1 and observation, it was determined that 32 residents reside in memory care with 12 residents identified as fall risk residents. Upon LPAs review of actual hours worked by caregivers, it was determined that three caregivers were on duty during the night shift on 10-26-21 until the morning of 10-27-21. Upon further review it was determined that S2 began shift at 10:25pm and clocked out at 7:00am, S3 began shift at 8:00pm and clocked out at 3:30am, S4 began shift at 10:15pm and clocked out at 7:00am. LPA reviewed staffing schedule on 11-17-21 and interviewed S1, which reveals 3 caregivers scheduled to work during the hours of 10:30pm to 7:00am on 10-26-21 until the morning of 10-27-21. Based on interviews, observation, and record reviews it is determined that R1 resides in memory care and fell at 5:00am on 10-27-21 and sustained injuries, and upon further review, determined that only one staff was on duty in memory care and one staff was on duty in assisted living at the time of R1’s fall and without the presence of additional staff member previously on duty. Incident report states this fall was unwitnessed. Therefore, this allegation is SUBSTANTIATED.
Allegation #2: Reporting party not notified of fall: LPA reviewed incident report for R1 dated 10-28-21. Based on review of incident report, there is no indication of responsible party being notified of fall incident occurring on 10-27-21 at 5:00am. Interviews with responsible person for R1 revealed no contact was made to responsible party in writing after the fall noted above. Interview with S1 revealed that it could not be confirmed if responsible party was notified of all noted above. Based on interviews and record reviews, this allegation is SUBSTANTIATED.
Allegation #3: Reappraisal not completed for change of condition: LPA reviewed appraisal forms for R1 on 11-17-21. An appraisal needs and service plan for R1 was observed by LPA to be dated 2-19-21 with no update regarding fall precautions relating to the fall of R1 which occurred on 10-27-21 at 5:00am. A reappraisal form for R1 was requested on 11-17-21 and was not located in R1s record. Based on record review and observation, this allegation is SUBSTANTIATED.
Allegation #4: Documents not provided to POA upon request. LPA conducted interviews with S1, and responsible person for R1. Based on interviews conducted, it was determined that a request for records relating to information on R1s fall on 10-27-21 at 5:00am was made by responsible person on 11-1-21 and not received by responsible person for R1 until 11-19-21. Based on interviews conducted, this allegation is SUBSTANTIATED.
As a result of today’s visit and the findings noted above, deficiencies are cited under Title 22, division 6. 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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20211116124932

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: 12/09/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/10/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Ammended from original report dated 12-9-21: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit staffing schedule to indicate appropriate levels of coverage necessary to meet residents’ needs. Schedule to be submitted to LPA by POC due date.
	8 9 10 11 12 13 14	Based on record reviews, interviews, and observation, R1 sustained a fall with injury...Licensee did not ensure R1 received appropriate care and supervision due to inadequate staff coverage. This poses an immediate health, safety, and resident rights risk to residents in care.	8 9 10 11 12 13 14	Licensee will conduct staff training on fall precautions and submit a scheduled training date to LPA by POC due date. Licensee will submit plan on providing adequate coverage to meet residents’ needs in the event of staff shortages. Plan to be submitted to LPA by POC due date.
Type B 12/20/2021 Section Cited CCR 87211(a)(1)(B)	1 2 3 4 5 6 7	Reporting Requirements (a) Each licensee shall furnish….reports as the Department may require…(1) A written report shall be submitted…to the person responsible for the resident within seven days of the occurrence…(B) Any serious injury….occurring while the resident is under facility supervision.	1 2 3 4 5 6 7	Licensee will read regulation 87211(a)(1) and submit a signed statement of understanding and agreeance to follow regulation.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews and record review, responsible person for R1 was not notified in writing of fall that occurred on 10-27-21 at 5:00am within seven days of occurrence. This poses a potential health, safety, and resident rights risk to residents in care.	8 9 10 11 12 13 14	Licensee will submit a plan to ensure responsible parties are notified appropriately following incidents as noted in regulation 87211(a)(1)

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: 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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 27-AS-20211116124932

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: 12/09/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/20/2021 Section Cited CCR 87463(a)	1 2 3 4 5 6 7	Reappraisals. (a) The pre-admission appraisal shall be updated in writing…as frequently as necessary to note significant changes and to keep the appraisal accurate.	1 2 3 4 5 6 7	Licensee will develop a plan to ensure all resident appraisals are updated as appropriate to meet the needs of residents in care. Plan to be submitted to LPA by POC due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on records review and interviews, facility did not update an appraisal form for R1 to address fall precautions and a fall event of R1 which occurred on 10-27-21 at 5:00am. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 12/20/2021 Section Cited CCR 87468.1(a)(9)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have…the following rights: (9) To have communications to the licensee from their representatives answered promptly and appropriately. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will read regulation 87468.1(a)(9) and submit a signed understand of regulation indicating agreeance to follow the regulation.
	8 9 10 11 12 13 14	Based on interviews, Licensee did not ensure responsible person for R1 was answered promptly when requesting documents relating to a fall event for R1. Documents were requested on 11-1-21 and not received until 11-19-21. This poses a potential health, safety, and resident rights risk to residents in care.	8 9 10 11 12 13 14	Licensee will conduct staff training to ensure communications from responsible persons of resident in care are answered timely. Proof of training to be submitted to LPA by POC due date.

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: 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

LIC9099 (FAS) - (06/04)

Page: 4 of 4