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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 08/04/2023
Date Signed: 08/04/2023 01:17:30 PM


Document Has Been Signed on 08/04/2023 01:17 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: 148DATE:
08/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Anuradha SainiTIME COMPLETED:
01:20 PM
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On 8-4-23 at 10:05am, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to conduct a case management visit regarding various incidents reported between May and July of 2023. Incidents reported were of resident to resident altercations. Incidents were reported to licensing department, ombudsman and local law enforcement per regulatory requirements. Based on record review it was determined that incidents occurred between afternoon and night shifts. Resident1 (R1) appeared in 3 of 9 incident reports reviewed today as the aggressor in the resident to resident altercations. R1 as since discharged after these incidents.

LPAs discussed with facility's director of nursing (S1) and Administrator various resources available and the need for further staff training on mental health interventions including the de-escalation of behaviors which may contribute to resident to resident altercations. At this time, Licensee and director of nursing have agreed to the following: (1) A designated facility staff member will conduct resident rounds across shifts and report any potential changes in physical or mental health well being. Licensee will ensure documentation of rounds to be conducted. (2) Licensee or designee will identify residents with history of behavioral challenges and provide additional resources in such areas including but not limited to: Crisis intervention, drug and alcohol abuse, and general mental wealth well-being. (3) Licensee or designee will conducted bi-weekly meetings with staff to ensure proper identifying and interventions for residents with mental health needs; documentation of meetings to be maintained. (4) Licensee or designee will ensure additional staff training on various mental health topics including but not limited to: De-escalation of behaviors and peer conflicts, identifying triggers for various behaviors, safe intervention techniques regarding aggression and anger. (5) Licensee or designee will ensure additional activities for residents in care.

Licensee made aware of intention for follow up on future visits. As a result of today's case management, no citations are issued today. An exit interview was conducted with Lucky Kaur and a copy of this report was provided to Lucky.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
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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