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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 11/23/2021
Date Signed: 11/23/2021 01:47:07 PM

Document Has Been Signed on 11/23/2021 01:47 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
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: 85DATE:
11/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH:Ian PhitnoukanhTIME COMPLETED:
01:45 PM
NARRATIVE
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On 11-23-21 at 9:56am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit due to incident reports received on 11-19-21. LPA met with Resident Care Coordinator (RCC) Ian Phitsanoukanh explained the purpose of the visit. Licensee was on premises and gave permission for Ian to sign and accommodate LPA during today's visit. LPA conducted a health and safety check during case management visit. LPA's temperature was checked and logged at entry. Sign in procedures were initiated. Facility temperature was 75*F throughout facility. Staffing included 3 caregivers in memory care and 1 med tech, 2 caregivers in Assisted Living and 1 med tech. Resident were eating lunch at 11:50am and served according to mealtimes and menu items. At 10:05am LPA reviewed 14 incident reports received on 11-19-21. 4 out of 14 incident reports were reported as unwitnessed falls. LPA also reviewed facility’s fall prevention program and conducted interviews with Resident1 (R1), Staff1 (S1) and S2. LPA also conducted observation of R1 relating to self-administered medication procedures at 12:45pm and reviewed medication log sheet and physician’s report for R1 at 12:10pm. Based on interviews and record reviews it was determined that R2, R3, R4, R5, and R6 are receiving fall prevention services. Based on review of medication log sheet, incident report, interviews, and observation it was determined that R1 is able to administer own medications accurately.

Additionally during review of incident report, it was determined that 6 of 14 incident reports were submitted to regional office beyond seven days of occurrence and not within reporting requirement regulations.

As a result of today’s visit, deficiencies are cited per Title 22 regulations, division 6, chapter 8. A civil penalty in the amount of $250 is assessed due to a repeat violation. An exit interview was conducted with Ian Phitsanoukanh and a copy of this report was left with Ian. Appeal rights provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/23/2021
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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Document Has Been Signed on 11/23/2021 01:47 PM - It Cannot Be Edited


Created By: Michael Bilger On 11/23/2021 at 01:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 11/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2021
Section Cited
CCR
80061(b)(1)(D)

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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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Licensee will submit a plan to ensure timely reporting of incidents to licensing department. Plan shall include a procedure for designating an individual in charge of auditing and ensuring accurate and timely reporting. Licensee to submit plan to LPA by POC due date.
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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 licensee did not ensure timley reporting of incident in 6 of 14 incident reports reviewed. This poses a potential health and safety risk for resident in care. Civil penalty assessed due to repoeat violation.
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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 King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2021


LIC809 (FAS) - (06/04)
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