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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 08/26/2022
Date Signed: 08/26/2022 05:04:08 PM


Document Has Been Signed on 08/26/2022 05:04 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:
08/26/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Lucky KaurTIME COMPLETED:
05:15 PM
NARRATIVE
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On 8-26-22 at 2:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit for an incident which occurred on 8-19-22. LPA met with Lucky Kaur and explained the purpose of the visit. Administrator Anuradha Saini was contacted by phone and LPA explained purpose of the visit. Administrator gave permission for Lucky to sign in her absence. LPA reviewed incident report dated 8-19-22 and interviewed staff1 (S1). Based on interview and record review, it was determined that resident1 (R1) eloped from facility on 8-19-22 at approximately 7:10pm. Facility staff searched surrounding areas, but unable to locate R1. Facility staff filed police report and were later notified by police that R1 had been found and taken to hospital. Incident report and interview also revealed that a staff member was sent to hospital to sit with R1 once learning of R1’s whereabouts.

Based on interviews and record review, it is determined that facility was unaware of R1’s whereabouts on 8-19-22 between 7:10pm and approximately 4:00pm on 8-20-22, resulting in an absence of supervision for R1. As a result, deficiencies are cited under Health and Safety Code, Chapter 3.2. In addition to citation issued, an immediate civil penalty in the amount of $500 is issued due to violation resulting in absence of supervision. An exit interview was conducted with Lucky Kaur and a copy of this report was left with Lucky. Appeal rights provided.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2022
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


Document Has Been Signed on 08/26/2022 05:04 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: 08/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2022
Section Cited

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Basic Service Requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (d) Being aware of the resident's general whereabouts… This requirement was not met as evidenced by:
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Based on interview and record review, Licensee did not ensure facility’s knowledge of R1’s whereabouts on 8-19-22 leading to an elopement episode and absence of supervision. This posed an immediate health, safety, and resident rights risk to resident in care. An immeidate civil penalty in the amount of $500 is being issued on today's visit due to the violation of absence of supervision Additional civil penalty may be assessed upon further department review.
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Licensee to conducted staff training on elopement policy and procedures. Training date to be submitted to LPA by POC due date. Training to be completed and proof of completed training sent to LPA no later than 2 weeks from citation issued date of 8-19-22.

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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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2022
LIC809 (FAS) - (06/04)
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