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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 03/05/2024
Date Signed: 03/11/2024 01:46:16 PM


Document Has Been Signed on 03/11/2024 01:46 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:A1 DEL MONTE STOCKTONFACILITY NUMBER:
392700993
ADMINISTRATOR:SANDEEP SAINIFACILITY TYPE:
740
ADDRESS:517 E. FULTON STREETTELEPHONE:
(209) 910-5910
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:158CENSUS: 155DATE:
03/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Sunny TIME COMPLETED:
12:15 PM
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LPA Johnson arrived to the facility unannounced to conduct a Case management visit regarding a self reported incident that occurred on 2/26/2024.

SIR, details R1 visit to the ER for a headache on 2/26/2024, while at the ER, R1 informed the hospital that there was an altercation with the roommate and that is the reason for the visit to the ER. The facility was unaware of the altercation until 2/27/2024.

The facility reviewed the discharge papers on 2/27/2024 and this is when the situation was discovered. The facility took action and notified the police department and the resident was moved to another room.

No deficiencies were cited on today's date.

LPA was able to obtained copies of resident's service plan and other pertinent information. Exit interview conducted.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
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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