<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 05/02/2022
Date Signed: 05/02/2022 06:38:01 PM


Document Has Been Signed on 05/02/2022 06:38 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:
05/02/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Anuradha SainiTIME COMPLETED:
04:22 PM
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
On 5-2-22 at 3:00pm, regional office conducted an informal meeting with facility to discuss recent citations issued and additional concerns. This meeting was held virtually via Teams Meeting. Present at the meeting were Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Michael Bilger, Ombudsman Kathryn Thomas, Licensee Sunny Saini, Administrator Anuradha Saini, and Regional Executive Director Jenna Silva. Topics in this meeting included the following: (1) Evictions, (2) Personal Rights, (3) Signal System, (4) Reporting Requirements, (5) Re-appraisals, and (6) Administrator Qualifications.

On 4-13-22 three eviction notices were given to Resident1 (R1), R2, and R3 which stated reasons for eviction to include drug and alcohol use as well as overdue rent payments. Eviction notices have since been rescinded and re-issued to reflect overdue rent as the sole reason for eviction. During this meeting, it was revealed by regional executive director that room searches did not occur, instead a "well-being check" occurred to ensure safety of residents. Regional executive director stated that alcohol bottles were found in "plain site". LPM and LPA discussed eviction notices and regulations, and personal rights with Licensee, Administrator and Regional Executive Director. LPM informed licensee that bottles and other materials cannot be confiscated without clear permission from residents. Additionally, in regards to evictions, LPA and LPM informed Licensee that appropriate documentation must be in place to justify an eviction and that internal documentation should be in place in addition to required incident reporting to licensing department. Licensee expressed concern regarding residents who are not following house rules and continue to drink and produce and unsafe environment for themselves. LPA and LPM informed Licensee that all such events should be documented and reported to licensing department. Licensee was made aware by LPA and LPM that personal rights must be honored when entering rooms and confiscating items. Licensee acknowledged understanding. Licensee stated facility is an alcohol and drug-free facility. LPM requested an update to plan of operations and admission agreement reflecting this and requested documents be sent to licensing department for approval prior to implementation. LPM made Licensee aware that an updated plan of operation must be submitted to licensing department if facility moves forward with a new transitional memory care unit. LPM discussed procedures including LIC 200 and fire department approval prior to such implementation. {Cont. on 809C}
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022
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


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
VISIT DATE: 05/02/2022
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
In regards to facility's signal system, signal system has not been functioning properly since LPAs discovery on 3-8-22 and hand held bells have been in place. Licensee informed LPA and LPM that call system is now currently functioning. Regional executive director demonstrated call button during meeting which indicated an alarm sound and signal to caregiver's device alerting them to the room number requesting assistance. Licensee stated a permanent solution is in process which includes phone units in each resident room, however, parts of been delayed due to supply shortage indicated by Licensee. Licensee stated that an additional permanent solution to the signal system beyond the required signal system currently in place should be completed within 60-90 days as re-programming of system will also need to occur once parts are delivered. LPM asked Licensee how signal systems are monitored to ensure proper functionality. Regional executive director responded and stated that each new caregiver is given a device and each shift check units to ensure they are functioning. Additionally, maintenance department checks weekly to ensure units are working properly. Licensee will ensure process continues.

Reporting requirements were addressed with Licensee, Administrator, and regional executive director. LPA discussed recent citations issued regarding medication errors not reported in addition to drug use and room searches. Regional executive director stated facility continues to use a communication form caregivers fill out to inform physician of any medication changes. Additionally, Licensee ensured LPA and LPM this process will continue and report additional instances relating drug and alcohol use as well as other instances which may affect the health, safety, or mental well-being of residents in care.

Re-appraisals were discussed. Regional executive director stated that a plan continues to be in place since January 2022 to update all resident appraisal needs and service plans and appraisals annually or if a significant change occurs prior to the annual review. Regional Executive Director also stated daily meeting are held to discuss conditions of residents and makes notes of conditions of changes. LPA informed Licensee and Administrator that if significant changes are identified they should reflect on new appraisals and needs and service plan. Licensee and Administrator acknowledged understanding.

LPM informed licensee and Administrator that Anuradha, who is the Administrator of Record must now be on premises 40 hours per week unless until a new administrator of record is in place. Anuradha acknowledged understanding and stated she will be on premises 40 hours per week. LPA requested an updated LIC 500 to reflect Anuradha's 40 hour schedule.

No deficiencies cited today. An exit interview was conducted with Anuradha Saini and a copy of this report was given to Anuradha with request for signature and return via email to licensing department.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2