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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 03/14/2022
Date Signed: 03/14/2022 05:15:59 PM


Document Has Been Signed on 03/14/2022 05:15 PM - It Cannot Be Edited

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: 98DATE:
03/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Jenna SilvaTIME COMPLETED:
05:25 PM
NARRATIVE
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On 3-14-22 at 2:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding an incident which occurred on 3-12-22. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. Regional Executive Director Jenna Silva was present and was given permission by Anuradha to sign on her behalf and accommodate LPA. LPA interviewed Administrator, regional executive director resident1 (R1) and Staff1 (S1). LPA also conducted observation on the facility’s memory care unit. On 3-14-22, facility reported to regional office an incident which occurred on 3-12-22 which involved resident1 (R1) exiting premises resulting in an absence without leave (AWOL). LPA reviewed R1’s physician report, and needs and service plan. Based on interviews and record reviews it was determined that R1 exited premises at approximately 9:30pm on 3-12-22 and returned to facility at appropriately 10:30am on 3-13-22 unharmed. According to physician’s report, R1 is not to leave facility unsupervised. LPA also reviewed staff schedule and actual hours worked for 3-12-22. Staff schedule and actual hours worked revealed 5 caregivers were on duty during the time of this incident. Interview with S1 revealed that S1 and another caregiver were attending to another resident and did not hear the door alarm sound to indicate a resident exiting. During facility observation, it was determined that alarm system is functioning properly. A review of the incident report dated 3-13-22 stated facility staff did not determine the reason for R1s AWOL. A review of physician’s report for R1 revealed that R1 has a history of wandering and indicates R1 has dementia..

Based on today’s visit. Deficiencies are cited under Title 22, Division 6. An exit interview was conducted with Jenna Silva and a copy of this report was given to Jenna. Appeal rights provided.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 03/14/2022 05:15 PM - It Cannot Be Edited

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: 03/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2022
Section Cited

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Care of Persons with Dementia. (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.
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This requirement is not met as evidenced by: Based on interviews and record reviews, Licensee did not ensure the staff present appropriately coordinate to address R1s wandering behavior resulting in R1 exiting facility unattended on 3-12-22. This poses an immediate health and safety risk to residents in care.
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Licensee to assess current alarm system and submit a tested audit of alarm system functionality to determine appropriate resident safety.

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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: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2