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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 07/12/2023
Date Signed: 07/12/2023 04:56:52 PM


Document Has Been Signed on 07/12/2023 04:56 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: 149DATE:
07/12/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Eddie ItliongTIME COMPLETED:
02:18 PM
NARRATIVE
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On 7-12-23 at 12:05pm, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to conduct a case management visit regarding a relocation of memory care door. LPAs met with business office manager Eddie Itliong and explained the purpose of the visit. Administrator Anuradha Saini was made aware of LPAs visit. On 6-20-23 LPA received LIC 200 and updated facility sketch from licensee indicating plans for memory care door relocation. At that time, Licensee was to not complete construction prior to clarification for the need to update fire clearance. Upon entry, LPAs observed memory care door was moved forward from previous spot allowing for extra rooms accessible to assisted living residents. LPAs interviewed Staff1 (S1) and Administrator. Based on interview and observation, it was determined that door construction was completed prior to a fire department consultation as well as an updated fire clearance. Moreover, it was determined that a building permit was not obtained prior to construction. Additionally, based on observation, the memory care door alarm was not functioning due to a malfunctioning bar door when tested by LPAs. During LPA's visit today, maintenance immediately repaired door to appropriate functional status as observed and tested by LPAs. Furthermore, it was determined based on interview and record review, that licensee did not ensure a plan of provision of safety during time of this construction to ensure adherence of memory care resident rights and overall safety.

Based on today's case management, deficiencies are cited under Title 22, Division 6. Immediate civil penalties in the amounts of $500 were issued in addition to citations due to fire safety hazards and fire clearance. An exit interview was held with Eddie Itliong and a copy of this report was left with Eddie. Appeal Rights provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023
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 3


Document Has Been Signed on 07/12/2023 04:56 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: 07/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2023
Section Cited
CCR
87203

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Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by:
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Door was repaired during LPAs visit and LPAs observed alarm to be functioning properly.

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Based on observation and interview, Memory care door alarm was not functioning in that bar door was unable to move forward, which poses an immediate health, safety, and resident rights risk to residents in care.
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Licensee will read regulation 87203 and submit a signed declaration of understanding to LPA by POC due date.
Type A
07/13/2023
Section Cited
CCR87202(a)

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Fire Clearance. (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal...This requirement was not met as evidenced by:
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Licensee will update LIC 200 and submit to LPA by POC due date as process for updating fire clearance.

Licensee will read regulation 87202 (a) and submit a signed declaration of understanding to LPA by POC due date.
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Based on interview and record review, Licensee initiated a relocation of memory care door without securing an updated fire clearance. This poses an immediate health and safety risk to residents in care.
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*Civil Penalty assessed for Fire Safety*
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: 07/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/12/2023 04:56 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: 07/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2023
Section Cited
CCR
87305(a)

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Alterations to existing buildings and new facilities. (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met as evidenced by:
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Licensee will submit proof of application for building permit to LPA by POC due date.

Licensee will read regulation 87305(a) and submit a signed declaration of understanding to LPA by POC due date.
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Based on interview and record review, licensee did not secure a buidling permit for an alteration regarding memory door relocation. This poses an immediate health and safety risk to residents in care.
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Type A
07/13/2023
Section Cited
CCR87405(h)(5)

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Administrator Qualifications-Duties. (h) The administrator shall have the responsibility to:(5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs...This requirement was not met as evidenced by:
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Licensee will read regulation 87405(h)(5) and submit a signed declaration of understanding to LPA by POC due date.
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Based on interview and record review, Licensee did not ensure a provision of safety for residents in that a plan to ensure resident rights and safety was not submitted in regards to a building alteration. This posed an immediate health and safety risk to residents in care.
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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: 07/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3