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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 05/05/2023
Date Signed: 05/05/2023 04:42:23 PM


Document Has Been Signed on 05/05/2023 04:42 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: 146DATE:
05/05/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Anuradha SainiTIME COMPLETED:
03:06 PM
NARRATIVE
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On 5-5-23 at 1:05pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding an eviction notice presented to resident1 (R1) and a current episode of scabies regarding R2. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. LPA reviewed eviction letter with Administrator and attempted interview with R1. Based on review of eviction letter, it was determined that letter was presented to R1 on 4-17-23, and a copy was not sent to Licensing department within required regulatory time frame.

LPA conducted facility tour and observed isolation carts outside of resident2 (R2) room who is diagnosed with scabies. LPA reviewed incident report with Administrator. Isolation cart contained appropriate personal protective equipment (PPE) available for staff and visitor use. LPA also observed staff members utilizing the PPE during today's tour. LPA also reviewed medication order for R2 and determined that physician's prescribed treatment is being followed by staff.

Based on today's case management visit, a citation issued under Title 22, Division 6, Chapter 8. An exit interview was conducted with Administrator and a copy of this report was left with Administrator. Appeal rights provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023
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 05/05/2023 04:42 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: 05/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2023
Section Cited

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Eviction Procedures. (f) A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement was not met as evidenced by:
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Licensee will rescind previous written eviction notice and so inform R1.

Licensee will send proof of rescinded notice to LPA by POC due date.
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Based on record review and interview, licensee did not ensure an eviction notice issued to R1 on 4-17-23 was sent to licensing department within regulatory time frame as noted above.
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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: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023
LIC809 (FAS) - (06/04)
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