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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 09/03/2021
Date Signed: 09/03/2021 01:37:44 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 STOCKTONFACILITY NUMBER:
392700993
ADMINISTRATOR:SAINI, ANURADHAFACILITY TYPE:
740
ADDRESS:517 E. FULTON STREETTELEPHONE:
(209) 910-5910
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:158CENSUS: 52DATE:
09/03/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Morgan WhineryTIME COMPLETED:
01:25 PM
NARRATIVE
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On 9/3/21 at 10:30am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit for an incident that occurred on 8/5/21. LPA met with Administrator Morgan Whinery and explained the purpose of this visit.
LPA reviewed the following documents: Resident1 (R1)'s service plan, hospital records, and previous incident reports. LPA also conducted interviews with Staff1 (S1) and S2. LPA also interviewed Day Program social worker for R1. Based on interviews with day program social worker, S1, and S2 and based on records reviews it was determined that R1 was at the day program on 8/5/21 and was sent to the emergency room (ER) after a registered nurse (RN) at the day program noticed a wound on R1's left leg with oozing puss needing attention. According to record review, RN sent R1 to ER for further evaluation of wound on 8/5/21. Based on interview with S2 and hospital record review, it was revealed that R1's wound was previously addressed by S2 on 7/12/21 and sent to ER for further evaluation and treatment. Based on interview with day program social worker it was revealed that day program attempted to call facility, but attempted the call using an phone number no longer in service and has since learned of the new phone number. As a result and based on additional interviews with S1 and S2, it was revealed that facility did not receive notification from day program on 8/5/21 that R1 had been sent out, and did not learn of R1's hospitalization until hospital notified facility of R1's time for discharge on 8/5/21. Upon further record review of incident reports, it was determined that an incident report for 8/5/21 was not received by licensing department until 9/3/21, and an additional incident report from 8/7/21 was not received by licensing department until 8/18/21.

Based on today's visit, deficiencies are being cited under Title 22 regulations, Division 8. An exit interview and a copy of this report along with appeal rights was left with Administrator Morgan Whinery.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2021
Section Cited

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Reporting requirements. (b) Upon the occurrence...of any of the events specified in (1)...a report shall be made to the licensing agency within the agency's next working day...a written report containing the information...shall be submitted to the licensing agency within seven days following the occurrence of such event.
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(1) Events reported shall include...(D)Any injury to any client which requires medical treatment. This requirement is not met as evidenced by: Based on record review and interviews, Licensee did not furnish incident reports for R1's hospitalizations on 8/5/21 and 8/7/21 in a timely manner. This posses a potential health and safety risk to residents in care.
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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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2021
LIC809 (FAS) - (06/04)
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