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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 03/08/2022
Date Signed: 03/08/2022 04:17:06 PM

Document Has Been Signed on 03/08/2022 04:17 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: 98DATE:
03/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:43 PM
MET WITH:Jenna SilvaTIME COMPLETED:
03:40 PM
NARRATIVE
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On 3-8-22 at 2:43pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit during an investigation for complaint #27-AS-20220222105340. LPA met with Regional Executive Director Jenna Silva and explained the purpose of the visit. Administrator Anuradha Saini was notified and gave permission for Jenna to accommodate LPA and sign in her absence. During complaint visit, it was revealed that an incident occurred in February 2022 regarding resident1 (R1) not receiving a prescribed blood pressure medication for a period of approximately 3 weeks. LPA interviewed Regional Executive Director. LPA also reviewed facility incident reports for February 2022. Based on interviews and record reviews it is determined that this incident was not reported by facility to licensing agency upon facility learning of difficulty in resolving this occurrence.

Deficiencies are issued based on today’s visit. An exit interview was conducted with Jenna Silva and a copy of this report was left with Jenna. Appeal rights provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2022
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 03/08/2022 04:17 PM - It Cannot Be Edited


Created By: Michael Bilger On 03/08/2022 at 03:03 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: 03/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2022
Section Cited
CCR
87211(a)(1)(D)

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Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports...:(1) A written report shall be submitted to the licensing agency…within seven days of the occurrence of any of the events specified…(D) Any incident which threatens the welfare, safety or health of any resident…
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Licensee will read regulation 87211 and submit a signed declaration of understanding to LPA by POC due date

Licensee will conduct staff training on regulation 87211 and submit proof of completed training to LPA by POC due date. Training from an outside vendor to be utilized.
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This requirement is not met as evidenced by: Based on interviews and record reviews, R1 did not receive prescribed blood pressure medications for approximately 3 weeks and incident was not reported to licensing agency. This poses 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 King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022


LIC809 (FAS) - (06/04)
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