392700993-7-28-2022-27-AS-LKIG-CH7VQ6-20220811163748

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700993
Report Date: 07/28/2022
Date Signed: 07/28/2022 11:45:38 AM

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
06/20/2022 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20220620090633

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:	DATE:	07/28/2022
		UNANNOUNCED	TIME BEGAN:	10:13 AM
MET WITH:			TIME COMPLETED:	11:50 AM

ALLEGATION(S):

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Facility is in disrepair
Staff did not meet resident's needs

INVESTIGATION FINDINGS:

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On 7-28-22 at 10:13am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver complaint findings for the allegations listed above. LPA met with Alicia Carranza and explained the purpose of the visit. Administrator Anuradha Saini was made aware of LPA's visit and gave permission for Alicia to sign in her absence. During this investigation, LPA interviewed two staff members and four residents. LPA also reviewed admission agreement for Resident1 (R1) and care notes from June 2020 for R1. In addition, LPA conducted a facility observation on 6-20-22.

Allegation #1: Facility is in disrepair. LPA interviewed R1 and R2 as well as Staff1 (S1) and Administrator. LPA also conducted facility observation. Based on interviews, the allegation of facility in disrepair specifically noted the in R1’s room window unable to open, as well as the air conditioning unit and bathroom fan in R1’s room. Based on observation by LPA, the window in R1’s room was able to open, close and lock without difficulty. In addition, LPA observed air conditioning unit to be producing cold air. LPA further observed R1’s room to be of adequate temperature with overall facility temperature 75*F on 6-20-22. LPA observed bathroom fan to be malfunctioning in bathroom. {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: 07/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220620090633

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: 07/28/2022

NARRATIVE

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Based on interviews, this malfunction was not reported to maintenance by R1, but was reported on day of LPA’s visit on 6-20-22 and repaired same day. Based on interviews conducted, there were no other items noted of concern in terms of disrepair. As a result, there is not a preponderance of to conclude facility is in disrepair at this time, therefore this allegation is UNSUBSTANTIATED.

Allegation #2: Staff did not meet resident's needs. LPA interviewed R1, and R2 as well as S1 and Administrator on 6-20-22. On 7-28-22, LPA interviewed R3 and R4.. LPA also reviewed care notes for R1 and Admission agreement for R1. Additionally, LPA conducted a facility observation on 6-20-22. Based on interviews, this allegation stated R1 was not receiving timely assistance for incontinence needs, personal items including medication not secured upon R1’s return on 6-20-22, and R1 not receiving a copy of her admission agreement. Based on interviews and observation, it was determined that R1 had left facility on 6-20-22 with an intention to discharge to another facility but returned same day. LPA observed boxes of R1’s personal items at 2:10pm and based on interviews, R1 returned to facility at approximately 1:30pm. LPA observed staff members entering room to offer assistance during LPA’s visit. Additionally, based on interviews, R1’s medication was secured and locked upon her return within approximately 15 minutes. LPA observed R1’s medication secured during observation. Based on record review of care notes, it is indicated that R1 has been receiving activities of daily living (ADL) care including incontinent care needs. Based on interviews and record reviews, it is indicated that R1 and other residents’ care needs are being addressed timely. Upon review of R1’s admission agreement, LPA observed an acknowledgment of receipt signature from R1 in the appropriate sections of Admission agreement. Based on interviews, record reviews and observation, there is not a preponderance of evidence to conclude that R1’s needs are not met by staff, therefore, this allegation is UNSUBSTANTIATED.

No citations issued as a result of this investigation. An exit interview was conducted with Anuradha Saini and a copy of this report was left with Anuradha. Appeal Rights provided.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

LIC9099 (FAS) - (06/04)

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