392700993-6-20-2023-27-AS-MBIR-CSZ2NZ-20230620173335

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 06/20/2023
Date Signed: 06/20/2023 05:33:45 PM

Document Has Been Signed on 06/20/2023 05:33 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:	06/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:04 AM
MET WITH:	Anuradha Saini		TIME COMPLETED:	05:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 6-20-23 at 10:04am, Licensing Program Analyst (LPAs) Michael Bilger and Arvin Villanueva arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Anuradha Saini and explained the purpose of the visit. LPA 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 of the facility to ensure compliance with Title 22 regulations. Facility is a residential care facility for the elderly with a current census of 144. Facility has 89 bedrooms and 89 bathrooms for resident use. Facility has a formal dining room LPA also conducted the inspection using the CARE tool. Facility currently provides care for 41 ambulatory residents, 103 non-ambulatory residents, 7 of these residents are receiving hospice care, and 0 bedridden. Water temperature reads 105F to 120F in the bathroom and room temperature reads 71*F. LPA 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. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 5-31-23. Facility has an emergency food and water kit. All toxins and other dangerous items including sharp objects were secured during today's visit. Medication storage area was observed to be locked and inaccessible to residents in care. Medications were reviewed for accuracy. First aid kit was observed to have adequate supplies and accessible to staff. During this inspection 8 resident files and 11 staffing files were reviewed for regulatory compliance. All staff noted on LIC 500 contained criminal background clearances. LPA completed 5 resident interviews and 5 staff interviews. Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. {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: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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: 06/20/2023

NARRATIVE

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Facility’s liability insurance is current and update to date per regulatory requirements. Facility does not contain any bodies of water. LPA observed personal rights, resident council and complaint information posted. Facility has appropriate internet access available for resident use. LPA observed facility’s activity calendar and sufficient equipment and supplies to meet activity program needs of residents in care. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts quarterly fire drills. LPA requested an updated copy of LIC 308 and LIC 500.

Per California Code of Regulations, Title 22, deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Anuradha Saini. 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: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/20/2023 05:33 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: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 5 out of 11 staffing files reviews. Health screening forms were completed more than 7 days after employee hire and facility licensure which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/20/2023
	Plan of Correction
1 2 3 4	Licensee will read regulation 87411(f) and submit a signed declaration of understanding to LPA by POC due date. Licensee will conduct staff file audit to bring any necessary health screening reports up to date. Results of audit to be sent 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: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC809 (FAS) - (06/04)

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