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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 04:20:48 PM

Document Has Been Signed on 03/08/2022 04:20 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:
03:45 PM
MET WITH:Jenna SilvaTIME COMPLETED:
04:45 PM
NARRATIVE
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On 3-8-22 at 3:45pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit during an investigation on complaint # 27-AS-20220223130051. LPA met with Regional Executive Director Jenna Silva and explained the purpose of the visit. Administrator Anuradha Saini was contacted and gave permission for Jenna to accommodate LPA and sign in her absence. During complaint visit it was discovered that facility’s signal system is not functioning properly. LPA tested eight rooms’ signal system by pressing provided emergency pendent located in residents’ rooms with 8/8 rooms unable to send a signal to staff to alert them of resident needs. LPA also interviewed regional executive director and licensee during visit.

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)
Page: 1 of 2
Document Has Been Signed on 03/08/2022 04:20 PM - It Cannot Be Edited


Created By: Michael Bilger On 03/08/2022 at 03:39 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 A
03/09/2022
Section Cited
CCR
87303(i)(A)(B)(C)

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Maintenance and Operation (i) Facilities shall have signal systems which shall...(1)All facilities licensed for 16 or more...shall:(A)Operate from each resident's living unit.(B)Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (C) Identify the specific resident living unit.
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Licensee will submit plan to ensure resident needs are met with alternative signal system until current system is repaired or replaced. Plan to be submitted to LPA by POC due date. Licensee has provided hand held bells for residents in care as of 3-8-22.
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This requirement is not met as evidenced by: Based on observation and interview, it was determined that facility's signal system did not function properly per regulatory requirements in 8 out of 8 resident rooms. This poses an immediate health, safety, and resident rights risk to residents in care.
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Licensee will repair or replace current signal system to meet regulatory requirements. A time frame for repair or replacement to be submitted 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: 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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