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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 02/02/2023
Date Signed: 02/02/2023 01:43:39 PM


Document Has Been Signed on 02/02/2023 01:43 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: 122DATE:
02/02/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Anuradha SainiTIME COMPLETED:
01:02 PM
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On 2-2-23 at 10:11am, Licensing Program Analyst ( LPA) Michael Bilger arrived at this facility unannounced to conduct a quarterly health and safety check visit. LPA met with Administrator Anuradha Saini and explained the purpose of the visit.
LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside area of the facility to ensure compliance with Title 22 regulations. Facility is a 158-bed assisted living facility for the elderly with a current census of 92. LPA was screened upon entry for temperature and asked to sign in. COVID screening questions were asked prior to entry. Facility has 77 bedrooms and 77 bathrooms. There is a formal dining room off the kitchen area for residents. All knives, toxins, and other chemicals were inaccessible to residents in care. "See something, Say something" poster was in place. Staff were wearing masks while on duty. Hand sanitizer was readily available. There were 10 caregivers and 3 med techs on duty, 3 kitchen staff, 2 housekeepers, assistant administrator, nurse, and Administrator on duty. Facility has 30-day supply of PPE on hand. Resident rights and rights of resident council notices posted. Emergency disaster plan and facility sketch updated and posted.
The facility has an approved a COVID mitigation plan. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and outside area including smoking area. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. Refrigerator temperature measured at 40*F. Freezer temperature measured at 0*F. Signal system in place and functional. {Cont. on 809C}
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023
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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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
VISIT DATE: 02/02/2023
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Water temperature reads between 105*F-120*F upstairs and downstairs and room temperature reads 76*F.upstairs and downstairs. LPA toured kitchen and observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings.

The facility common areas were clean and furnished with floors and walls clean and odor free throughout. Smoke and carbon detectors were in good repair. Facility has an emergency food and water kit. Fire extinguishers are fully charged and last inspected 7/1/22. Five resident charts reviewed and contained all required documentation including updated needs and service plans and physician's reports. Facility is reporting incidents per regulatory time frames and has a current updated plan of operation in place. Staffing schedule reflect Administrator on duty at least 40 hours per week.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Anuradha Saini.

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

DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023
LIC809 (FAS) - (06/04)
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