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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 02/09/2022
Date Signed: 02/09/2022 05:22:43 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: 92DATE:
02/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:51 PM
MET WITH:Jenna SilvaTIME COMPLETED:
05:27 PM
NARRATIVE
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On 2-9-22 at 2:52pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue a case management visit for an incident reported on 1-5-22. LPA met with Regional Executive Director Jenna Silva and explained the purpose of the visit. Administrator Anuradha Saini was notified of LPAs visit and gave permission for Jenna to accommodate LPA and sign in her absence. According to incident report dated 1-5-22, an encounter between two male residents was witnessed by Staff1 (S1) on 1-4-22 which required separation of residents. LPA reviewed incident report with Regional Executive Director and interviewed Regional Executive Director and (S1). LPA also conducted a health and safety case management check. LPA was screened for COVID upon entry. Social distancing was practiced and COVID-19 signage was in place. Facility temperature was at 75*F. Facility was clean and sanitary with no foul odors. Sharp objects, toxins, and other dangerous items were inaccessible to clients in care. LPA screened facility for COVID questions upon entry.

Based on interviews conducted today, it was determined that knowledge of suspected abuse occurred but was not reported timely per regulatory reporting requirements. Incident report and interview revealed Resident1 (R1) sustained redness of a body part after an encounter with R2. Citations are issued today based on Title 22 regulations, 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: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2022
Section Cited

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c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1).
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This requirement is not met as evidenced by: Based on interviews conducted an incident of suspected abuse occurred on 1-4-22 and was not reported timely to local law enforcement and ombudsman. 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: 02/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2022
LIC809 (FAS) - (06/04)
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