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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700993
Report Date: 06/08/2023
Date Signed: 06/08/2023 02:53:52 PM

Unfounded


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
05/31/2023 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20230531115408
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: 144DATE:
06/08/2023
UNANNOUNCEDTIME BEGAN:
12:51 PM
MET WITH:Lucky KaurTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff abandoned resident at hospital
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 6-8-23 at 12:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to open and investigate the complaint allegation noted above. LPA met with Director of Nursing Lucky Kaur and explained the purpose of the visit. LPA reviewed physician’s report for resident1 (R1), incident report dated 5-30-23, functional capability assessment for R1, and discharge paperwork for R1. LPA also interviewed S1as part of this investigation. Based on interviews and record review it was determined that R1 was sent to the hospital by facility staff on 5-26-23. It was further determined through record review that R1 was accepted back to facility on 6-1-23 Additional record review revealed R1discharged self from facility on 6-2-23 at 3:20pm.

As a result, of this investigation, there is a not a preponderance of evidence to conclude that R1 was abandoned by facility staff after being sent to the hospital. Therefore, this allegation is UNFOUNDED.
An exit interview was conducted with Lucky Kaur and a copy of this report was provided to Lucky
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
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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