392700993-5-17-2023-27-AS-MBIR-CRX27G-20230517170843

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 05/17/2023
Date Signed: 05/17/2023 05:08:47 PM

Document Has Been Signed on 05/17/2023 05:08 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 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: 144	DATE:	05/17/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Anuradha Saini		TIME COMPLETED:	05:08 PM

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On 5-17-23 at 2:15pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a complaint investigation regarding incident reports received on 3-23-23, 4-18-22, 4-22-23, and 5-10-23. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. LPA reviewed incident reports with Administrator and conducted interview with Administrator. LPA also reviewed needs and service plans for Resident1 (R1), R2, R3, R4, and R5.

Incident #1: LPA reviewed incident report dated 3-23-23 which states R1 and R2 were witnessed by facility staff to be pushing each other while in the dining room, including R1 pulling R2’s hair. Based on interview and record review, facility staff intervened and separated residents. A light bruise was discovered around R1’s eye. Facility staff attempted emergency personnel contact and R1 refused. Record review further indicates local law enforcement was called and event was reported on a SOC 341 form and sent to licensing department and ombudsman within regulatory time frames. Interviews and record reviews revealed interventions are in place to include increased supervision and monitoring of residents’ behaviors. Interventions are noted on an updated needs and service plan for R1 and R2.

Incident #2: LPA reviewed incident report dated 4-18-23 which states R4 was engaging in disruptive type behavior including yelling at other residents, staff, and visitors at random. Based on interview and record review, it was revealed that staff intervened appropriately to redirect R4. Updates were observed on needs and service plan for R4 to reflect new interventions put in place including increased supervision and redirection techniques. Interviews further revealed Administrator is in contact with R4’s responsible person for additional options. Incident was reported per regulatory requirements.

Incident #3: LPA reviewed incident report dated 4-22-23 which states R4 informed facility staff that R3 hit him in the back of the head while in the dining room. Based on interviews and record reviews, an internal investigation was conducted which did not reveal any witnessing of said event, however, did reveal a witness to R4 scratching R3’s arm. {Cont. on 809C}

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

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: 05/17/2023

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As a result, R3’s arm was treated by facility staff with standard first aid. Incident was reported per regulatory requirements. Interventions for behaviors have been updated on needs and service plan for R4 and R5.

Incident #4: LPA reviewed incident report dated 5-10-23 which states R5 and R3 were engaged in an altercation in which R5 threw a food item at R3. No injury reported. Facility reported incident per regulatory requirements. Based on interviews and record reviews, it was revealed that facility staff was present and redirected residents from altercation. Interventions are in place to reflect behavior patterns and needs and service plans are updated at this time.

Based on today’s case management visit, no deficiencies are observed. An exit interview was held with Anuradha Saini and a copy of this report was left with Anu.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC809 (FAS) - (06/04)

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