392700993-3-5-2024-27-AS-KHOS-D3PL7B-20240325083006

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700993
Report Date: 01/24/2024
Date Signed: 03/05/2024 11:56:44 AM

Substantiated

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: 158	DATE:	01/24/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Elizabeth Phitsanovkanh		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff hit resident.
Staff caused injury to resident.

INVESTIGATION FINDINGS:

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This report has been amended to include additional information that was reported by the facility.

On 1/24/24 at approximately 1:00pm Licensing Program Analyst (LPA) Albert Johnson arrived at facility unannounced to continue the compliant investigation into the above listed allegations. LPA Johnson met via phone with Elizabeth Phitsanovkanh and explained the purpose of today's visit. LPA Johnson entered the facility but was informed that there is a Covid Outbreak. LPA went back to the car to finish the report.

Allegations: Staff hit resident and Staff caused injury to resident. Based on records reviewed on 1/18/2024 it was discovered that on date unknown R1 was knocking on the cafeteria door when S1 aggressively swung the door open and hit R1 with the door. As a result of the incident R1 had a “knot” on her head. R1 was transported to St. Jospeh Hospital to be examined. R1 did not have any fractures.

The allegations are substantiated. An exit interview was conducted, and a copy of the 9099 report, LIC 9099-D, and appeal rights were given to the facility.

Substantiated

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: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 27-AS-20231005125740

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/24/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/25/2024 Section Cited CCR 87468.1	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.	1 2 3 4 5 6 7	Licensee is to ensure that all inservice trainings are documented and residents' personal rights are upheld at all times.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by the actions of S1 opening the door to the kitchen without regard causing an injury to R1. This is an immediate safety risk for residents in care.	8 9 10 11 12 13 14	Please submit a letter of understanding and a copy of the completed in-service training to include date and signatures of trainer and attendees by POC due date.
Type A 03/06/2024 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:	1 2 3 4 5 6 7	The facility has completed the in service training fro Personal rights. The plan of correction was completed on 1/25/2024.
	8 9 10 11 12 13 14	(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by R1 sustaining an injury.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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: 158	DATE:	01/24/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Elizabeth Phitsanovkanh		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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9

Call button not accessible to resident.
Staff left resident in soiled diapers for a period of time.
Staff does not administer medication as prescribed.
Staff did not properly supervise resident causing resident to fall.
Staff left resident in disrepair bed.
Staff hit resident. (Second allegation of hitting)

INVESTIGATION FINDINGS:

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The report is being amended to address the additional allegation of Staff hit resident.

Allegation: Staff hit resident. Based on attempted interviews with the resident, staff and The Director of nursing the facility investigated the incident and was unable to determine if R1 was hit by S1. S1 denied the incident and stated that R1 is in memory care and the residents there will do things, but we are trained on how to not take incidents personally and redirect them to another activitiy. The allegation is unsubstantiated

Allegation: Call button not accessible to resident. During the tour of the facility with Elizabeth Phitsanovkanh at approximately 1:20pm on 1/18/2024, LPA observed telephones in each resident's room that is set inbetween the resident areas. The call system that is beside the bed is not working and is missing hardware or pull strings. The facility is aware of the challenge for residents to get acess to the call buttons and is addressing the need by installing call system through-out the facility. It is noted that the facility has recently installed a call system through out the facility. The allegation is unsubstantiated

Allegation: Staff left resident in soiled diapers for a period of time. Based on records reviewed and interviews with residents and staff, the facility has provided the department with documentation showing that the facility does incontinence care rounds every two hours and the documentation identifies who what and when the briefs were changed. The allegation is unsubstantiated

Unsubstantiated

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: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20231005125740

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: 01/24/2024

NARRATIVE

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Allegation: Staff does not administer medication as prescribed. Review of R1's medication administration record did not indicate R1 was being given any excessive amounts of Lorazepam. LPA reviewed the medication administration record for R1 and did not find any medication errors for R1 or any other resident record reviewed. LPA reviewed five other residents' records. Based on this information LPA was unable to identify any other medication errors. The allegation is unsubstantiated

Allegation: Staff did not properly supervise resident causing resident to fall. Based on records reviewed R2 did have a fall on 9/20/2023 and was sent to the ER, R2 was not on a stand assist for toileting or dressing. The facility did assess R2 for fall risk and it was not targeted as support. The facility revised the service plan to support R2 as a fall risk after this incident. R2 has a new service plan that addresses the potential for falls. The allegation is unsubstantiated.

Allegation: Staff left resident in disrepair bed. Based on records reviewed the department was able to determine that on 8/21/2023, R2's bed was making a squeaking noise when R2 would move, Staff heard the noise and went to inspect the bed and noticed that the bed was broken(a support beam was loose). Staff notified the maintenance director and the bed was replaced. The duration of how long the bed was making noise is unknown.
The allegation is unsubstantiated.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred. The Department has determined that the allegations are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies noted or cited per California Code Regulation, TITLE 22

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4