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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 03/24/2023
Date Signed: 03/24/2023 05:07:14 PM


Document Has Been Signed on 03/24/2023 05:07 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: 137DATE:
03/24/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Anuradha SainiTIME COMPLETED:
05:30 PM
NARRATIVE
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On 3-24-23 at 4:00pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding an incident which occurred on 2-28-23. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. LPA interviewed Administrator and reviewed incident report dated 2-28-23, as well as physician's report for R1. Based on interview and record review, it was determined that on 2-28-23 at approximately 7:15am, resident1 (R1) was sitting outside of the facility. A med tech (S1) encourage R1 to come inside due to cold weather. R1 stated he will come back after his routine walk. At 8:15am, S1 attempted to check on R1 and was unable to locate R1. S1 and other facility staff checked R1's room and surrounding areas of facility as well as areas across the street from facility, but unable to locate R1. At approximately 9:00am, R1 arrived back at facility accompanied by local law enforcement.

Based on review of physician's report for R1, R1 is unable to leave building unassisted. Facility staff reported incident within regulatory time frames. Facility staff is currently in process of assessing R1 for placement within secured unit of facility.

Due to facility unaware of R1's whereabouts, citation is issued under Health and Safety code 1569.312(d). An immediate civil penalty in the amount of $1000 is issued to facility in addition to citation due to repeat violation within 12 month period. An exit interview was conducted with Anuradha Saini and a copy of this report was left with Anuradha. Appeal rights provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023
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 03/24/2023 05:07 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: 03/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/27/2023
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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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.
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Based on interview and record review, Licensee did not ensure facility’s knowledge of R1’s whereabouts on 2-28-23 leading to an absence of supervision. This posed an immediate health, safety, and resident rights risk to resident in care.
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Licensee will submit a plan outlining procedures for maintaining knowledge of residents whereabouts at all times. Plan to be submitted to LPA by POC due date.

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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: 03/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023
LIC809 (FAS) - (06/04)
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