392700993-1-6-2022-27-AS-MBIR-CAERPS-20220106121224

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 01/06/2022
Date Signed: 01/06/2022 12:13:40 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 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: 94	DATE:	01/06/2022
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	10:01 AM
MET WITH:	Anuradha Saini, Sunny Saini, Jenna Silva		TIME COMPLETED:	11:15 AM

NARRATIVE

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An Informal Conference was conducted at 10:00am on 1/6/22 at the Sacramento Regional Office virtually via Teams Meeting. Present for the meeting was Administrator, Anuradha Saini, Licensee Sunny Saini , Regional Executive Director Jenna Silva, Licensing Program Manager (LPM) , Liza King and the writer of this report Licensing Program Analyst (LPA), Michael Bilger .

The purpose of the informal conference was to address the facility’s compliance issues. The Department has concerns stemming from site inspections on multiple dates during the year 2021.

The licensee was told that this Informal conference is a part of the Administrative Action process and that further citations may result in an elevation to a formal non-compliance conference that could then lead to referral to the Department's legal division for possible revocation of license. Issues discussed during the meeting were:

1. 87413(a)(1) Personnel-Operations: In each facility, when regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. (Memory care unit was left unattended during an assist with 911 personnel in the assisted living section)

2. Care and Supervision: The Licensee shall provide care and supervision as necessary to meet the client’s needs. (Licensee did not ensure a proper repositioning and lift was performed for a resident in care for purposes of promoting fall prevention)
3. 80061(b)(1)(D)Reporting requirements: (b) Upon the occurrence...of any of the events specified in (1)...a report shall be made to the licensing agency within the agency's next working day...a written report containing the information...shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include...(D)Any injury to any client which requires medical treatment (Facility did not furnish timely incident reports for incidents occurring on 8/5/21 and 8/7/21) {Cont. 809D}

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022

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
	VISIT DATE: 01/06/2022

NARRATIVE

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4. 87211(a)(1)(B) Reporting Requirements: 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. (Facility did not inform responsible person in writing of a fall occurring on 10-27-21
5. 87411(a) Personnel Operations: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... (Licensee did not ensure R1 received appropriate care and supervision due to inadequate staff coverage and resident sustained a fall with injury)
6. 87468.1(a)(9): Personal Rights: Residents in all residential care facilities for the elderly shall have…the following rights: To have communications to the licensee from their representatives answered promptly and appropriately. (Licensee did not ensure responsible person was answered promptly when requesting records due to a fall).
7. 87463(a). Reappraisals. The pre-admission appraisal shall be updated in writing…as frequently as necessary to note significant changes and to keep the appraisal accurate. (Licensee did not ensure an updated appraisal was completed for a resident due to a fall event on 10-27-21)

In an effort to support the facility maintaining substantial compliance with health and Safety Statute and Title 22 regulations, the Department is developing a plan with the licensee to address causes for concerns.

Plan to address compliance concerns:

Facility will now ensure at least 2 staff are on duty at all times in each assisted living and memory care units. This plan also includes coverage for staff who take scheduled breaks. Additionally, this plan includes the utilization of on-call staff and supervisors to fill in for shifts when necessary. Inservice training was completed to address this plan. This plan was implemented on 12-1-21.

Facility has trained staff in regard to repositioning and lifting of residents as necessary. Staff to receive on-going training on when to call 9-1-1 for emergencies and when a proper repositioning may be performed to promote fall prevention. Facility will also be contracting with outside agencies for additional training. Training records to be maintained at facility and available for review by the Department as necessary. LPM requested copy of training schedule for January and February.

{Cont. on 809C}

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022

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
	VISIT DATE: 01/06/2022

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Facility shall continue to maintain a binder for all incident reports. The binder will contain blank incident reports and made available to staff. Procedure to include: (1) Staff fills out incident report and places in binder, (2) Binder is brought into facility’s daily meeting for incident report reviews, (3) Management staff to discuss incident reports, (4) Incident reports to be sent to Department.

Facility has developed and will continue to implement a reporting template to notify responsible persons in writing of incidents within 7 days.

Facility has developed and will continue to implement a checklist to ensure all appropriate parties are notified of incidents including responsible persons, physician, and the Department.

Facility to implement cross-training of staff to help ensure all resident needs are met. Plan includes cross training housekeeper as caregiver and night shift coverage. Plan to be implemented on 1-3-22

Reappraisals will now be tracked by date of when they are due. A marked date will be placed on resident binders to alert staff when reappraisal is up for renewal. Case conferences are to be completed on a monthly basis to address high risk residents, and to include review of current appraisal with resident and/or responsible person as applicable. Case conferences are to be implemented by 1-26-22. A Director of Nursing was hired and is currently assisting with this process.

The department will provide additional case management visits

No deficiencies are cited during today’s meeting. An Exit interview was conducted with Anuradha Saini and Jenna Silva, and copy of this report was provided to Anuradha and Jenna via email with request for return with signature.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022

LIC809 (FAS) - (06/04)

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