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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700993
Report Date: 06/07/2024
Date Signed: 06/10/2024 10:21:22 PM

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
05/06/2024 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240506133927
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: 156DATE:
06/07/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Sunny STIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility has pests infestations
INVESTIGATION FINDINGS:
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On 6/7/2024 LPA Johnson made an unannounced visit to deliver findings for the complaint investigation. Based on records reviewed the facility had an inspection of rooms and as a result there is an ongoing issue with bedbugs throughout facility. Various rooms at property have been positively identified with current bedbug activity during the past year. The exterminators suggest that service recommendation is a Monthly Proactive Continuous & Comprehensive, bedbug inspection & monitoring program. The service suggestion is to inspect 14 rooms per month at time of inspection and to perform inspection of all (84) rooms bi-annually. The technician will install bedbug interceptors or volcanoes (with approval of Delmonte management). The allegation is 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 RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
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
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
05/06/2024 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240506133927

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: 156DATE:
06/07/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Sunny STIME COMPLETED:
12:30 PM
ALLEGATION(S):
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9
Facility management not providing for appropriate scabies treatment
Facility staff are falsifying medication records
INVESTIGATION FINDINGS:
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Allegation: Facility management not providing for appropriate scabies treatment. Based on record reviewed and interviews conducted the facility appears to be addressing the issues with documentation to support the treatment of 14 residents in care. The treatment included oral medications and topical ointments. The facility confirmed that they are providing PPE for Staff while providing care for those who were being. The department was unable to confirm that the facility provided PPE for all staff at all times during the treatment period.

Allegation: Facility staff are falsifying medication records. LPA reviewed the medication administration records, interviewed med-techs and inspected medication carts. Continued
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: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20240506133927
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: 06/07/2024
NARRATIVE
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The Department was unable to confirm based on the investigation that the facility was falsifying medication records. The Department lacks evidence to support the allegation.

As a result of this investigation, this Department finds the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted with Administrator
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20240506133927
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: 06/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
06/14/2024
Section Cited
CCR
87303(a)
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Maintenance and Operation. (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
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The facility is actively working with a local exterminator to remedy the incidents and to prevent reoccurrence.
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Based on record reviews and interviews, Licensee is addressing the situation with a routine bed bug treatment service after an initial bed bug occurrence.
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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: 06/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4