392700993-8-10-2022-27-AS-CACL-CHBS4Q-20220815133307

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700993
Report Date: 08/10/2022
Date Signed: 08/10/2022 03:45:19 PM

Substantiated

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
08/09/2022 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220809162235

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: 92	DATE:	08/10/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Anuradha Saini		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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9

Resident's room is in disrepair

INVESTIGATION FINDINGS:

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13

On 08-10-2022 at 9:30 am, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit in regards to a complaint investigation with the above allegation. LPA Martinez met with Anuradha Saini and explained the purpose of today's visit.

During this investigation, LPA Martinez conducted interviews and observed resident rooms. Resident 1's (R1) had dead flies on the floor and window sill, which were removed by facility staff. In addition, R1's room had food debris on the floor. I R1's closet rails had dirt build up and dirt on the closet floor. Also, resident 2's closet rails had dirt build up and dirt on the closet floor, which their blankets were placed on the closet floor next to dirt. As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted, and a copy of the 9099 report, LIC 9099-D, and appeal rights were given to the facility.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220809162235

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
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 CCR 87303(a)	1 2 3 4 5 6 7	87303 (a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	Facility staff agrees to conduct a housekeeping and facility maintenance and operation training for all housekeeping staff by POC date 08/24/2022. Facility will email LPA Martinez copies of training sign in sheet and training materials by POC date 08/24/2022.
	8 9 10 11 12 13 14	This requirement was not met as evidence by: based on observation and interview review, LPA Martinez observed R1 and R2 bedroom were unsanitary and not in good repair. This posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	Facility has installed bug zappers in the facility.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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
08/09/2022 and conducted by Evaluator Avelina Martinez

COMPLAINT CONTROL NUMBER: 27-AS-20220809162235

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: 92	DATE:	08/10/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Anuradha Saini		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not safeguard resident's property

INVESTIGATION FINDINGS:

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

On 08-10-2022 at 9:30 am, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit in regards to a complaint investigation with the above allegations. LPA Martinez met with Anuradha Saini and explained the purpose of today's visit.

During this investigation, LPA Martinez conducted interviews and observed resident rooms. LPA Martinez inspected resident 1's (R1) room. LPA Martinez observed R1's clothes in their bedroom drawers. LPA Martinez also observed a brief and female sanitary napkins in R1's room. During the visit, R1's belongings were in thier room. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated. An exit interview was conducted, and copy of this report was given to the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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