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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 08/10/2022
Date Signed: 08/10/2022 03:51:01 PM


Document Has Been Signed on 08/10/2022 03:51 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: 92DATE:
08/10/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Anuradha SainiTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit. LPA met with Anuradha Saini and explained the purpose of the visit.

Today's case management visit is in response to: facility staff did not treat resident 1 (R1) with dignity, and R1 was not free from humiliation by staff. LPA Martinez observe staff 1 (S1) speak to resident 1 (R1) in a deeming manner. Staff 1 yelled at R1 due to their health issues and having to clean their bedroom floor due to a health condition. Moreover, Staff 2 (S2) questioned R1 on how they spend their money in an unprofessional manner. S2 further stated R1 was spending their money on drugs, and S2 had no substantial evidence or basis to accuse R1 of this expenditure. As a result, the facility was cited personal rights deficiency, which can be found on the 809-D Page.

The following deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022
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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Document Has Been Signed on 08/10/2022 03:51 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/24/2022
Section Cited

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Personal Rights of Residents in All Facilities 87468.1(a)(1) residents in all residential care facilities for the elderly shall have all of the following personal rights: to be accorded dignity in their personal relationships with staff...This requirement was not met as evidence by:
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Based on observation: staff 1 and staff 2 did not provide R1 with dignity. This posed a potential health and safety risk to resident 1 (R1).
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Type B
08/24/2022
Section Cited

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Administrator - Qualifications and Duties 87405(d)(5) The administrator shall have the qualifications specified in Sections 87405...Good character and a continuing reputation of personal integrity. This requirement was not met as evidence by:
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Based on observation facility administrator did not implement personal integrity. this posed a potential health and safety risk to R1.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022
LIC809 (FAS) - (06/04)
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