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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 10/14/2022
Date Signed: 10/14/2022 03:35:10 PM


Document Has Been Signed on 10/14/2022 03:35 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:
10/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Anu Saini, AdministratorTIME COMPLETED:
01:30 PM
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On 10/14/22, Licensing Program Analyst (LPA) Renee Campbell arrived at A1 Del Monte Assisted Living and Memory Care at approximately 12:15 pm to conduct a case management visit regarding an incident report submitted to CCLD 09/08/22. LPA was greeted by Administrator Anu Saini, and explained the purpose of the visit.

Based on the incident report, while in their shared room Resident1, (R1) slapped Resident (R2) three times because R2 would not lower the volume on the television. Both residents were separated and sent to different rooms. 911 was called so that a report could be filed and a SOC 341 was completed.

Based on observations, documents and interviews, facility followed procedure. A report was filed with the police, an incident report was submitted to licensing and R1's behavior was updated in her Behavior Progress notes. After the police were called, residents were moved to separate rooms to address the situation. The administrator and staff were interviewed as well. Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
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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