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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700993
Report Date: 03/16/2022
Date Signed: 03/16/2022 11:04:17 AM

Substantiated


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
02/22/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220222105340
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:
03/16/2022
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Jenna SilvaTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Medication- Resident not receiving Blood Pressure medication for 3 weeks.

Medication- Facility not following Physicians order.

Medication- Facility staff failed to notify resident's Physician regarding medication.

Administrator- Qualifications
INVESTIGATION FINDINGS:
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On 3-16-22 at 10:10am Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver complaint findings for the allegations noted above. LPA met with regional executive director Jenna Silva and explained the purpose of the visit. Administrator Anuradha Saini was contacted and gave permission for Jenna to accommodate LPA and sign in her absence. Throughout this investigation LPA interviewed staff1 (S1), S2, S3, and S4. LPA also reviewed medication log sheets and orders for resident1 (R1) and reviewed facility progress notes along with Administrator’s certificate and on-duty schedule. Based on interviews and record reviews conducted, it was determined that facility received a blood pressure medication for R1 from R1’s responsible party on 1-31-22 which contained a discrepancy between the physician’s order on file and the label on the bottle. Label on the bottle read “one time per day” and the order on file stated: “two times per day.” It was further revealed through interviews and record reviews that this medication was not given to R1 for a period of longer than 3 weeks.

{Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 27-AS-20220222105340
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: 03/16/2022
NARRATIVE
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Furthermore, there was no indication of an order to stop giving the blood pressure medication, or any indication that R1 refused medication. Progress notes for R1 reviewed revealed three entries regarding medication order discrepancy. An entry on 2-3-22 states pharmacy was called. The following entry was on 2-15-22 which states clinic was called and staff was waiting for a response “within 24 hours.” The last entry was on 2-18-22 which states a staff member notified R1’s responsible person asking for assistance in obtaining a medication list. The progress notes did not specifically state a specific physician was notified to address the medication discrepancy. This information was also confirmed through staff interviews. Based on additional interviews it was determined that Administrator did not ensure a practice necessary to aid in resolving the medication discrepancy for R1 described above.

Based on the interviews conducted and records reviewed, it is determined that the preponderance of evidence standard it met, therefore the above allegations are SUBSTANTIATED. 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.

This document has been amended to reflect additional citations noted on LIC 9099 dated 4-8-22.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20220222105340
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/17/2022
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4)The licensee shall assist residents with self-administered medications as needed.
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Licensee will submit a plan to ensure residents are receiving medications as ordered. Plan to be submitted to LPA by POC due date


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This requirement is not met as evidenced by: Based on interviews and record reviews, Licensee did not ensure R1 receive a prescribed blood pressure medication for a period of more than 3 weeks. This poses an immediate health and safety risk to residents in care.
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Licensee will ensure staff training on medication regarding physician’s orders and working with pharmacies is completed. Proof of training to be sent to LPA by POC due date.
Type A
03/17/2022
Section Cited
CCR
87405(h)(5)
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Administrator-Qualifications and Duties. (h) The administrator shall have the responsibility to: (5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs…This requirement is not met as evidenced by:
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Licensee will submit a plan to ensure Administrator staff effectively communicate to meet residents’ needs.
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Based on interviews and record reviews, Licensee did not ensure Administrator communicate effectively with designee, other staff, and outside entities to resolve a medication order discrepancy for R1’s blood pressure medication resulting in R1 not receiving medication for a period longer than 3 weeks. This poses an immediate 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: 03/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
02/22/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220222105340

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:
03/16/2022
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Jenna SilvaTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Personal Right- Facility failed resident to see family member.
INVESTIGATION FINDINGS:
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On 3-16-22 at 10:10am, Licensing Program Analysts (LPA) Michael Bilger arrived unannounced to deliver findings for the complaint allegation noted above. LPA met with Jenna Silva and explained the purpose of the visit. Administrator Anuradha Saini was notified and gave permission for Jenna to accommodate. LPA and sign in her absence. The allegation described an alleged incident where a visitor was not allowed to visit due to COVID precautions. During the investigation for this allegation, LPA reviewed facility’s COVID-19 mitigation plan, interviewed complainant, and interviewed regional executive director. LPA also conducted a facility observation to address COVID precautions and screening procedures. Based on interviews, it was determined that facility followed visitation guidelines appropriately and visitor was allowed to visit through alternative methods per guidelines.
Based on interviews, record reviews, and observations it is determined that the preponderance of evidence standard is not met, therefore this allegation is UNFOUNDED.

An exit interview was conducted with Jenna Silva and a copy of this report was given to Jenna.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4