392700993-8-15-2023-27-AS-LKIG-CUZ7A4-20230823212856

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700993
Report Date: 08/15/2023
Date Signed: 08/15/2023 11:50:59 AM

Unsubstantiated

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
07/07/2023 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20230707094713

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: 147	DATE:	08/15/2023
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Lucky Kaur		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not address change in residents condition in a timely manner
Staff are not properly cleaning facility restrooms

INVESTIGATION FINDINGS:

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On 8-15-23 at 11:15am, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to deliver findings for the complaint allegations noted above. LPAs met with Director of Nursing Lucky Kaur and explained the purpose of the visit. During this investigation, LPA interviewed 8 staff members and 3 residents. LPA also conducted a facility observation on 7-12-23 and 8-4-23. LPA also reviewed facility file documentation including staffing schedule and actual hours worked for July 2023, physician’s report for resident1 (R1), needs and service plan for R1, housekeeping task schedule, and relevant incident reports.
Allegation #1: Staff did not address change in resident’s condition in a timely manner. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews, it was revealed that R1 experience a sudden change in condition while on an outing outside of facility grounds. Interviews and record reviews further revealed that R1 was brought back by a responsible person for R1, and facility staff member not on duty was notified by responsible person via phone.
{Cont. on 9099C}

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230707094713

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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

NARRATIVE

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This facility staff member then notified medication technician on duty prior to R1’s return who proceeded to address the change of condition upon R1’s return. Interviews further revealed that R1’s condition was addressed which included attempts to get R1 to respond and check vital signs. Additionally, it was revealed that 9-1-1 was notified within an adequate time frame, and R1 returned to facility without additional medical complications. Additionally, investigation did not reveal any corroborated statements of untimely medical attention for R1 or other residents during this approximate time period.
As a result of this investigation, there is not a preponderance of evidence to concluded that facility did not act in a timely manner regarding resident’s change in condition. Therefore, this allegation is UNSUBSTANTIATED.

Allegation #2: Staff are not properly cleaning facility restrooms. LPA conducted facility observations on 7-12-23 and 8-4-23. LPA also conducted interviews as noted above and reviewed housekeeping task schedule. Based on observations conducted, interviews, and record reviews, it was revealed that facility restrooms are cleaned regularly and monitored to mitigate unsanitary conditions. Observations did not reveal unsanitary conditions throughout facility restrooms. Interviews did not reveal any corroborated statements of unsanitary or lack of housekeeping attention to facility restrooms.
As a result, there is not a preponderance of evidence to conclude that facility staff are not properly cleaning facility restrooms, therefore, this allegation is UNSUBSTANTIATED.

An exit interview was conducted with Lucky Kaur and a copy of this report was provided to Lucky. 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: 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

LIC9099 (FAS) - (06/04)

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