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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 04/08/2022
Date Signed: 04/08/2022 03:17:14 PM


Document Has Been Signed on 04/08/2022 03:17 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: 99DATE:
04/08/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Jenna SilvaTIME COMPLETED:
03:10 PM
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On 4-8-22 at 1:55pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a plan of correction visit for a citation issued on 3-8-22 regarding facility’s current signal system. LPA met with Jenna Silva and explained the purpose of the visit. Facility’s signal system was distorted after an interruption in internet service provider which is required for signal system to fully function in facility. At this time, facility is continuing to utilize an alternative signal system using hand held bells and focused supervision for resident safety. LPA interviewed Licensee who stated that new parts are on order and expected to arrive today 4-8-22, which is expected to result in signal system functioning within approximately one week once in place and appropriately tested. Interview with Licensee also revealed that there have been shipping delays for required parts. Additional interviews were conducted with Resident1 (R1), (R2), and (R3). Interviews revealed hand held bells are currently in place. LPA observed hand held bells in place in various resident rooms.

No deficiencies cited today. An exit interview was conducted with Jenna Silva and a copy of this report was left with Jenna.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022
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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