392700993-4-22-2022-27-AS-KHOS-CDWMAC-20220428092609

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700993
Report Date: 04/22/2022
Date Signed: 04/22/2022 04:03:10 PM

Unsubstantiated

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
02/23/2022 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20220223130051

FACILITY NAME:	A1 DEL MONTE STOCKTON		FACILITY NUMBER:	392700993
ADMINISTRATOR:	SAINI, ANURADHA		FACILITY TYPE:	740
ADDRESS:	517 E. FULTON STREET		TELEPHONE:	(209) 910-5910
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95204
CAPACITY:	158	CENSUS: 94	DATE:	04/22/2022
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Jenna Silva		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Questionable Death
Staff did not respond to resident in a timely manner
Facility not following COVID-19 guidelines

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 4-22-22 at 10:45am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue investigation and deliver findings for the complaint allegations noted above. LPA met with Regional Executive Director 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. During this investigation, LPA interviewed 5 residents, 4 staff and executive director. LPA also conducted facility observation on 3-8-22 and 4-22-22. Records reviewed included COVID-19 mitigation plan, COVID-19 screening log, incident report for Resdient1 (R1), and functional capability assessment for R1. Investigation Bureau (IB) conducted assignment to obtain death certificate for R1 and acute hospital records for R1 which were reviewed by LPA.
Allegation#1: Questionable Death. Based on records reviewed and interviews conducted, it was determined that R1 was sent to the hospital on 1-7-22 due to symptoms including dizziness, runny nose, weakness, and high blood pressure. {Cont. on 9099C}.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

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 2

Control Number 27-AS-20220223130051

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: 04/22/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Hospital records reviewed also revealed that R1 tested negative for COVID-19 at facility on 1-6-22 and positive for COVID-19 on 1-7-22 at the hospital. Hospital records reviewed also state R1 was sent to a skilled nursing facility from hospital on 1-10-22 and weakness began to progress. Hospital records further state that R1 was sent back to the acute hospital on 1-15-22 and returned to skilled nursing facility on 1-16-22. Death certificate reviewed states R1 passed away on 1-31-22 due to Parkinson’s disease with a contributing factor of COVID-19. Based on interviews and record reviews, it was determined that R1 was sent to acute hospital after an identified emergency need was addressed by staff at facility and reported to licensing department per regulations. Interviews and record reviews also revealed that R1’s needs were addressed in an appropriate time frame. A diagnoses of COVID-19 was reported on 1-7-22 at hospital. Interviews revealed that even though a COVID-19 outbreak was occurring during the time period of R1’s hospital admission, COVID-precautions were followed at facility. Facility observations on 3-8-22 and 4-22-22 revealed COVID-19 precautions were followed. Based on interviews, record reviews, and observations, it is determined that there is not a preponderance of evidenced to conclude that R1 passed away as a direct result of facility’s actions, therefore this allegation is UNSUBSTANTIATED. Allegation #2: Staff did not respond to resident in a timely manner: Based on record reviews and interviews, it was determined that R1 was experiencing symptoms including high blood pressure, runny nose, dizziness, and weakness at facility on 1-7-22 and was sent to acute hospital on 1-7-22. Record review of incident report reveals symptoms were noticed on 1-7-22 and sent to acute on 1-7-22 by facility staff. Additional interviews revealed that R1 tested negative for COVID-19 on 1-6-22 with no observed symptoms described above. Interviews further revealed that on 1-7-22, R1 originally refused to be sent to acute hospital but later agreed to be sent. Record reviews from hospital state upon hospitalization, R1 stated weakness as a complaint but denied other symptoms including fever, chills, nausea, vomiting, chest pain, and shortness of breath. Interviews with resident2 (R2), R3, R4, and R5 revealed needs are consistently met timely by staff. Based on record reviews and interviews, it is determined that there is not a preponderance of evidence to conclude R1’s needs were not met timely, therefore this allegation is UNSUBSTANTIATED. Allegation #3: Facility not following COVID-19 guidelines (UNSUBSTANTIATED): LPA conducted facility observations on 3-8-22 and 4-22-22, and interviewed R2, R3, R4,, R5, and R6. LPA also interviewed regional executive director, staff1 (S1), and S2. Based on interviews and observations, it was revealed that facility is following general COVID precautions including available hand sanitizer in appropriate locations, COVID-19 signage in appropriate locations, available Personal Protective Equipment (PPE) for 30 days, COVID-19 symptom screening at front door, appropriate COVID-19 record keeping, on-going COVID-19 testing as required, and staff compliance with mask while on facility premises. LPA also observed designated COVID-19 rooms available as needed and observed staff following PPE procedures and precautions. LPA also observed facility dining room to contain signage indicating 1 or 2 persons to a table depending on table size and promotion of social distancing. LPA also observed social distancing promoted at outside smoking patio. Based on interviews and observation, it is determined that there is not a preponderance of evidence to conclude that facility is not consistently following COVID-19 guidelines, therefore this allegation is UNSUBSTANTIATED.
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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2