392700993-3-24-2023-27-AS-KHOS-CQZPN6-20230418112721

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700993
Report Date: 03/24/2023
Date Signed: 03/24/2023 05:33:25 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/20/2023 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20230320082353

FACILITY NAME:	A1 DEL MONTE STOCKTON		FACILITY NUMBER:	392700993
ADMINISTRATOR:	SAINI, ANURADHA		FACILITY TYPE:	740
ADDRESS:	517 E. FULTON STREET		TELEPHONE:	(209) 910-5910
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95204
CAPACITY:	158	CENSUS: 137	DATE:	03/24/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Anuradha Saini		TIME COMPLETED:	12:07 PM

ALLEGATION(S):

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Staff does not ensure facility is kept in good repair
Staff does not ensure resident medical information is kept confidential

INVESTIGATION FINDINGS:

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On 3-24-23 at 9:45am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to open and investigate a complaint for the allegations noted above. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. LPA interviewed Administrator, staff1 (S1), S2, S3, and S4. LPA also conducted facility observation and reviewed additional documentation including photographs related to above allegations.

Allegation #1: Staff does not ensure facility is kept in good repair. LPA conducted interviews as stated above, facility observation, and reviewed photographs. Based on observation and interviews it was determined that a window seal in room 107 was damaged for a period of 2-3 weeks and not yet repaired. Window seal contained cracks and paint peeling from multiple areas. As a result, there is a preponderance of evidence to conclude faclity sustained an item in ill repair, therefore, this allegation is SUBSTANTIATED.

{Cont. 9099C}

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230320082353

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/24/2023

NARRATIVE

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Allegation #2: Staff does not ensure resident medical information is kept confidential. LPA conducted staff interviews as stated above and reviewed additional documentation. Based on interviews and record review, it was determined that staff member sent a photograph of a medication bottle for Resident2 (R2) to the wrong intended recipient resulting in medical information exposed. Interviews conducted confirmed information was sent in error and was corrected as required. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

As a result of this investigation, citations are issued under Title 22, Division 6. A civil penalty in the amount of $250 is issued 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 provided to Anuradha. Appeal rights provided.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20230320082353

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 B 04/04/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times...This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee has repaired damage to window seal and send photo proof of repair to LPA. Licensee will submit a plan outlining how future repair items will be addressed timely. Plan to submitted to LPA by POC due date.
	8 9 10 11 12 13 14	Based on observation and interview, window seal in room 107 contained damage for 2-3 weeks after occurrance. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 04/04/2023 Section Cited CCR 87468.2(a)(2)	1 2 3 4 5 6 7	Additionial Personal rights...(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities...(2) To have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will read regulation 87468.2(a)(2) and submit a signed declaration of understanding to LPA by POC due date.
	8 9 10 11 12 13 14	Based on record review and interview, Licensee did not ensure confidential medical information for R2 in that a photograph of medication information was sent to the wrong receipient. This posed a potential health, safety and resident rights risk to residents in care.	8 9 10 11 12 13 14	Licensee will submit plan outlining procedures for safely and effectively communicating private information to the appropriate parties. Plan to be submitted to LPA by POC due date.

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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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