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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 03:15:11 PM


Document Has Been Signed on 04/08/2022 03:15 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: 94DATE:
04/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Jenna SilvaTIME COMPLETED:
01:50 PM
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On 4-8-22 at 12:45pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding an incident which occurred on 4-3-22. LPA met with Regional Executive Director Jenna Silva and explained the purpose of the visit. Administrator Anuradha Saini was made aware of LPA’s visit and gave permission for Jenna to accommodate LPA and sign in her absence. LPA interviewed Administrator, Resident1 (R1) and R2 and reviewed incident report and resident records for R1 and R2. Based on interviews and record reviews it was determined that on 4-3-22, R1 and R2 were noted by staff to engage in an action in facility’s memory care unit which required facility to report. Based on interviews, it was determined that this action was mutual and without violation of resident rights. Record review and interview has determined that increase focus of supervision and updated plans of care are in place for R1 and R2 to address behaviors and safety measures. Facility reported incident to licensing department, ombudsman, and local law enforcement per regulations.

LPA conducted facility observation of memory care unit at 12:50pm. Unit alarm doors are functioning and staffing levels were appropriate during observation. All toxins and other dangerous materials are not accessible to residents in care. Temperature of unit was between 68*F and 85*F. Fire extinguishers were fully charged. Unit was clean and sanitary with no foul odors noted.

No deficiencies noted. 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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