392700993-1-12-2024-27-AS-KHOS-D3PL7C-20240325083007

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700993
Report Date: 01/12/2024
Date Signed: 01/12/2024 02:25:26 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
10/05/2023 and conducted by Evaluator Albert Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20231005125740

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: 156	DATE:	01/12/2024
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Eddie Itliong and Elizabeth Phitsanovkanh		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
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5
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7
8
9

Questionable death.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 1/12/24, LPA Johnson arrived to deliver findings for the above listed allegations. LPA met with Staff. The department investigated the questionable death allegation and discovered that R1's cause of death was listed on R1's death certificate as cardiac arrest and senile degeneration of the brain. There were no other significant conditions contributing to R1's death and no indication there was anything questionable about R1's death. Review of R1's medication administration record did not indicate R1 was being given any excessive amounts of Lorazepam.

The department has investigated the complaint alleging an questionable death. The department has found that the complaint is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Unfounded

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

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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