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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700993
Report Date: 05/01/2024
Date Signed: 05/01/2024 01:25:09 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
02/20/2024 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240220142324
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: 152DATE:
05/01/2024
UNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:S. SandeepTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Questionable death
Resident’s wound worsened due to staff neglect
INVESTIGATION FINDINGS:
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Allegation: Questionable death. Based on the death certificate and medical records obtained, R1 showed signs of a change of condition on the morning of 1-30-2024, and R1 was sent to the hospital. R1 was admitted for “acute hypoxic respiratory failure and status epilepticus.” R1 had a past medical history of end-stage renal disease on hemodialysis, bipolar disorder, seizure disorder, and reported history of paroxysmal atrial fibrillation. R1 passed away on 2-11-2024 due to Acute Respiratory Failure with Hypoxia, Status Epilepticus and Covid-19. End Stage Renal Disease was listed as a secondary cause of death.

Based on records reviewed and information obtained, R1 passed away due to medical complications. As there is nothing to indicate questionable death, this case has been investigated and is unfounded.
Unfounded
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
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 6
Control Number 27-AS-20240220142324
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: 05/01/2024
NARRATIVE
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Allegation: Resident’s wound worsened due to staff neglect. Based on review of the medical records by the department the facility assisted R1 with the new and existing medical conditions. R1's medical history on examination from the ER detailed a variety of conditions all conditions had been or were being addressed by the facility. The ER did not suspect or address any concerns of neglect of lack of care resulting in the worsening of wounds or death. The ER summarized a complete body check with no signs of lower extremity edema.  Based on the records reviewed and information obtained, R1 did not have medical need for wound care or was being treated for wounds of the lower extremities, this case has been investigated and is unfounded.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
02/20/2024 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240220142324

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: DATE:
05/01/2024
UNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff did not ensure resident was afforded privacy
INVESTIGATION FINDINGS:
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Allegation: Staff did not ensure resident was afforded privacy. Based on touring the facility and interviews with the staff. R1's room was an access point for the shower and the bathroom. The facility used a curtain to divide R1's living space from the entry point to the shower/bathroom. This is a personal rights violation. 87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet.

Substantiated.
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
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 6
Control Number 27-AS-20240220142324
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: 05/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2024
Section Cited
CCR
87307(a)(2)(c)
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87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet.
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The facility has addressed the room access point and has established an alternative enrty into the shower /bathroom area.
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This requirement was not met as evidenced by based on touring the facility and interviews with the staff. R1's room was an access point for the shower and the bathroom.
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POC cleared.
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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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
02/20/2024 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240220142324

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: DATE:
05/01/2024
UNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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3
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Staff did not provide adequate supervision resulting in resident sustaining multiple falls and injuries

Staff did not respond to resident’s calls for assistance in a timely manner

Staff did not ensure the facility was clean and sanitized
INVESTIGATION FINDINGS:
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Allegation: Staff did not provide adequate supervision resulting in resident sustaining multiple falls and injuries. Based on records reviewed and interviews with the staff the facility had a current service plan for R1 and the plan included stand assist and fall prevention services for R1. The facilities staffing schedule was reviewed and appeared to be adequate for the service needs of the facility. The reported falls at the facility appeared to be unwitnessed and upon staff finding R1 the facility would call emergency services to have R1 assessed by the emergency room. The department is unable to confirm that lack of supervision resulted in R1's falls. The facility staffing is consistent including two Med-Techs, five direct support staff, three maintenance or janitorial staff, one nurse and two executive staff. These supports vary from evening -to- day. The facility revised the service plan to support R1 as a fall risk. R1 had a new service plan that addresses the potential for falls. The allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20240220142324
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: 05/01/2024
NARRATIVE
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Allegation: Staff did not respond to resident’s calls for assistance in a timely manner. Review of records and interviews with residents the facility is answering calls, the times vary in each situations and on the average the calls are being answered within 5 to 15 minutes after the call buttons are pushed. Residents interviewed confirmed that the staff make good efforts at trying to answer all calls timely. The facility has installed an updated call system in each residents room. The system notifies the front desk and alerts staff on their communication devices when the call buttons are pushed. by residents.

Allegation: Staff did not ensure the facility was clean and sanitized. Based on observation on multiple visits on 1/24/2024, 2/15/2024, 2/21/2024 and 3/25/2024. The facility appears to be clean. However, photos taken by the reporting party show a blood stain on the bathroom wall of R1 and toilet paper on the ground. These photos are not complete stories of the cleanliness of the facility but they do show that the facility was not clean when the pictures were taken. This could have been immediately after a resident finished in the bathroom before a staff could get to it or it may have been there for sometime. The department is unable to determine if the photos of the two issues represent the facilities lack of cleanliness or sanitation.

The department has investigated the allegations and determined them to be unsubstantiated. There is not a preponderance of evidence to conclude the allegations are factual, therefore, these allegations are UNSUBSTANTIATED.



SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6