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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 08/15/2023
Date Signed: 08/15/2023 01:49:52 PM


Document Has Been Signed on 08/15/2023 01:49 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: 147DATE:
08/15/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Lucky KaurTIME COMPLETED:
01:50 PM
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On 8-15-23 at 12:15pm, Licensing Program Analysts ( LPA) Michael Bilger and Arvin Villanueva arrived at this facility unannounced to conduct a quarterly health and safety check visit. LPA met with Assistant Executive Director Lucky Kaur and explained the purpose of the visit.
LPA Bilger 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 area of the facility to ensure compliance with Title 22 regulations. Facility is a 158-bed assisted living facility for the elderly with a current census of 147. Facility has 77 bedrooms and 77 bathrooms. There is a formal dining room off the kitchen area for residents. All knives, toxins, and other chemicals were inaccessible to residents in care. "See something, Say something" poster was in place. There were 10 caregivers and 3 med techs on duty for resident care. Resident rights and rights of resident council notices posted. Emergency disaster plan and facility sketch updated and posted.
The facility has an approved infection control plan in place. The facility has a designated infection control lead. Refrigerator temperature measured at 40*F. Freezer temperature measured at 0*F. Signal system in place and functional. Memory care door was tested and determined to be functioning properly. Water temperature reads between 105*F-120*F upstairs and downstairs and room temperature reads 75*F.upstairs and downstairs. LPA toured kitchen and 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 with floors and walls clean and odor free throughout. Smoke and carbon detectors were in good repair. Facility has an emergency food and water kit. Fire extinguishers are fully charged and last inspected 5/31/23.

{Cont. on 809C}
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023
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 2


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: 08/15/2023
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Five resident charts reviewed and contained all required documentation including updated needs and service plans and physician's reports. Staffing schedule reflects Administrator on duty at least 40 hours per week.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Assistant Executive Director Lucky Kaur.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2