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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700993
Report Date: 10/23/2024
Date Signed: 10/24/2024 09:11:58 AM

Document Has Been Signed on 10/24/2024 09:11 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 STOCKTONFACILITY NUMBER:
392700993
ADMINISTRATOR/
DIRECTOR:
SANDEEP SAINIFACILITY TYPE:
740
ADDRESS:517 E. FULTON STREETTELEPHONE:
(209) 910-5910
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 158CENSUS: 153DATE:
10/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:SandeepTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 10/23/2024, LPA Johnson arrived at the care facility to conduct a case management visit into an incident report received regarding a medical emergency.

The report and supporting documents confirmed that R1 was able to leave the facility unassisted.

On 10/16/2024, The facility received notification from Stockton police department that R1 was involved in a hit-and-run accident. R1 was walking when the event occurred and was struck by a vehicle. Nearby people called the authorities and She was taken to the hospital for further evaluation.

The facility informed R1’s son of the situation, and he was able to speak with R1 directly. The hospital notified the facility that surgery would be required.

On 10/17/2024, the facility received a call from the hospital and the coroner office, informing them that R1 had passed.

LPA Johnson obtained copies of resident's file information.



No deficiencies cited during this visit.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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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