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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 04:11:36 PM


Document Has Been Signed on 10/14/2022 04:11 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:
01:30 PM
MET WITH:Anuradha SainiTIME COMPLETED:
02:45 PM
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On 10-14-22 at 1:30pm, LPAs Michael Bilger and Renee Campbell arrived unannounced to conduct a case management visit due to an incident which occurred on 9-10-22. LPAs met with Administrator Anuradha Saini and explained the purpose of the visit. LPA Bilger conducted interview with Administrator and reviewed incident report dated 9-12-22. Based on interview and record review it was determined that on 9-10-22, resident1 (R1) caused damage to the ceiling sprinkler in R1’s room resulting in water damage and flooding within the room which also caused the alarms to sound. The damage resulted in air conditioning unit to malfunction for a brief period of time and the temporary relocation of memory care residents to another location of the facility.

Based on interview, memory care residents were relocated to the dining room area temporarily with sufficient staffing numbers for supervision including monitoring of all exit doors until returning to room same day. Residents in care were provided fans and hydration as necessary. Resident room temperature was monitored by on duty staff to ensure sufficient temperature range. Air conditioning unit was functioning fully on 9-12-22, then slightly malfunctioning on 9-14-22 due to the 9-10-22 incident, and repaired same day to fully functional status. No disruption in care or other resident activity reported. Meals remained served on time and fans continued to be provided for all residents in memory care.

Incident was reported to licensing department within regulatory guidelines. No deficiencies cited as a result of today’s visit. An exit interview was conducted with Anuradha Saini and a copy of this report was left with Anuradha.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
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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