392700993-1-29-2024-27-AS-KHOS-D26R29-20240205113759

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700993
Report Date: 01/29/2024
Date Signed: 01/29/2024 04:13:22 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/11/2023 and conducted by Evaluator Maja Jensen

COMPLAINT CONTROL NUMBER: 27-AS-20231211164202

FACILITY NAME:	A1 DEL MONTE STOCKTON		FACILITY NUMBER:	392700993
ADMINISTRATOR:	RODRIGUES, JUDY		FACILITY TYPE:	740
ADDRESS:	517 E. FULTON STREET		TELEPHONE:	(209) 910-5910
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95204
CAPACITY:	158	CENSUS: 156	DATE:	01/29/2024
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Sunny Saini-Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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unlawful eviction

INVESTIGATION FINDINGS:

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On 1/29/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegation. LPA Jensen met with Sunny Saini and explained the purpose of today's visit.

During the course of the investigation LPA Jensen interviewed 2 staff members and reviewed records related to resident 1 (R1) including the Admission Agreement, Individual Service Plan, Physician's Report and Resident Notice to Leave Facility Voluntarily.

Staff 1 (S1) and Staff 2 (S2) were interviewed separately and both stated that R1 expressed a desire to leave the facility and was not stopped from doing so. Based on the records reviewed R1 signed and dated a notice to leave the facility voluntarily in October of 2023. The signature on the notice to leave voluntarily matches the signature on the admission agreement dated 11/18/21.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

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-20231211164202

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: A1 DEL MONTE STOCKTON	FACILITY NUMBER: 392700993
	VISIT DATE: 01/29/2024

NARRATIVE

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The Physician's report states R1 is able to leave the facility unassisted and is able to manage their own cash resources. The Admission Agreement sections related to termination of the agreement was determined to be in compliance with regulation. Based on LPA Jensen's review of the aforementioned documentation and the interviews conducted the allegation of unlawful eviction is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened, or is without a reasonable basis.

No deficiencies are being cited as a result of this investigation. An exit interview was conducted with Anu Sainin and a copy of this report was handed to her.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC9099 (FAS) - (06/04)

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