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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 07/07/2021
Date Signed: 07/07/2021 03:53:44 PM

Document Has Been Signed on 07/07/2021 03:53 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:LASLEY, KARONFACILITY TYPE:
740
ADDRESS:517 E. FULTON STREETTELEPHONE:
(925) 222-0430
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 158CENSUS: 54DATE:
07/07/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Anuradha Saini, AdministratorTIME COMPLETED:
02:15 PM
NARRATIVE
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On 7/7/21 at 12:30pm, Licensing Program Analyst (LPA) Michael Bilger conducted an unannounced case management visit to discuss a recent eviction letter issued to Resident1 (R1). LPA met with Administrator Anuradha Saini and explained the purpose of the visit. LPA reviewed eviction notice issued to R1. Based on review of eviction notice, it is determined that the document does not meet the minimum required components based on Title 22 regulation 87224 and was improperly issued to R1 on 6-30-21. Missing components include but may not be limited to: Proper date of eviction, resources made available to R1, statement of right of appeal for R1, and Statement provided as noted in Health and Safety Code 1569.683(a)(4).

As a result of today's visit, deficiencies are cited under Title 22 Regulations, Division 8. An exit interview was conducted with Anuradha. A copy of this report and appeal rights were left with Anuradha.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2021
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 07/07/2021 03:53 PM - It Cannot Be Edited


Created By: Michael Bilger On 07/07/2021 at 02:24 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: 07/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/08/2021
Section Cited
CCR
87224(d)(1)

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87224 Evicition Procedures (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement is not has evidenced by:
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Licensee will immediately notify R1 of improper issuance and rescind notice. Notice of reecission shall be in writing, signed by both parties and issued to R1, and a copy to be sent to LPA by POC due date.

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Based on record review, Licensee did not ensure all requirement components of the eviction letter issued to R1 including proper date of eviction, resources, notitice of right to appeal and required statement as specificed in Health and Safety Code 1569.683(a)(4). This poses a potential health, safety, and resident rights risk to residents in care.
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Licensee will read section 87224 Eviction Procedures and submit a signed statement of understanding to LPA by POC due date.

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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: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2021


LIC809 (FAS) - (06/04)
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