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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 07/12/2022
Date Signed: 07/12/2022 05:05:45 PM


Document Has Been Signed on 07/12/2022 05:05 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: 85DATE:
07/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Anuradha SainiTIME COMPLETED:
05:05 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 7-12-22 at 3:15pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit related to recently submitted death reports. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. LPA reviewed death reports for Resident1 (R1), and R2 and accompanying documentation with Administrator.

Death Report #1: Death report stated R1 was sent to acute hospital on 5/6/22 due to a fall and facility was notified or R1's passing on 6-10-22. LPA reviewed accompanying death certificate submitted by facility staff indicating R1 passed away due to Alzheimer's Disease on 6-1-22. Incident report relating to R1's fall was received timely on 5-7-22 and death report was received timely on 6/14/22.

Death Report #2: Death report stated R2 was found unresponsive on 6-19-22 and passed away on the same date. and had a Do Not Rescussitate (DNR) on file. LPA interviewed Administrator regarding events prior to death. Based on interviews, it was determined that R2 was considered for hospice care by R2's physician, but unable to be admitted due to lack of responsible party signature for authorization per hospice agencies. It was further determined through interview that physician for R2 instructed facility to provide comfort measure in lieu of traditional hospice care. Death report was received timely on 6-23-22.

No deficiencies issued as result of today's visit. An exit interview was conducted with Anuradha Saini and a copy of this report was left with Anuradha.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022
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 1