392700993-1-19-2022-27-AS-KHOS-CAZJQC-20220125061453

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700993
Report Date: 01/19/2022
Date Signed: 01/19/2022 12:35:06 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
01/03/2022 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20220103131036

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:	01/19/2022
		UNANNOUNCED	TIME BEGAN:	09:56 AM
MET WITH:	Marievec Andrade		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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COVID-19 precautions are not being followed

INVESTIGATION FINDINGS:

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On 1-19-22 at 9:56am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue investigation for the allegation noted above and deliver findings. LPA met with Director of Nursing Marievec Andrade and explained the purpose of the visit. Administrator Anuradha Saini was notified of LPA’s visit and gave permission for Marievec to accommodate LPA and sign necessary paperwork. Throughout this visit and other visits pertaining to this investigation LPA interviewed five staff members, four residents, and conducted facility observations on 1/4/22, 1/11/22, and 1/19/22. LPA also reviewed facility’s COVID-19 mitigation plan. LPA observed residents and staff wearing appropriate personal protective equipment (PPE) throughout facility. LPA also observed facility designating various rooms for quarantine including quarantined section with dedicated staff bathroom and breakroom. Dining room and smoking areas were observed by LPA to promote social distancing. Appropriate COVID precaution signage was observed to be in place. LPA was screened upon entry for temperature and symptoms, and hand sanitizer was available at the sign in desk upon facility entry. {Cont. on LIC 9099C}

Unsubstantiated

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: 01/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220103131036

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: 01/19/2022

NARRATIVE

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Based on interviews with residents, it was stated that precautions are being followed and masks as well as other PPE are being provided as necessary. Based on interviews with staff, it was stated that precautions are followed, with necessary on-going training on precautions to reinforce on-going practice of COVID-19 precautions.
Based on observations and interviews conducted, it was determined that there is not a preponderance of evidence to prove COVID-19 precautions are not followed on a routine basis. Therefore, the allegation noted above is UNSUBSTANTIATED.
An exit interview was conducted with Marievec Andrade and a copy of this report was left with Marievec. 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: 01/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022

LIC9099 (FAS) - (06/04)

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