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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201249
Report Date: 03/18/2026
Date Signed: 03/18/2026 03:18:57 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/26/2026 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20260226101220
FACILITY NAME:DELTA SHORES ASSISTED LIVINGFACILITY NUMBER:
079201249
ADMINISTRATOR:JARED PICKARDFACILITY TYPE:
740
ADDRESS:825 E 18TH STREETTELEPHONE:
(925) 706-7944
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:90CENSUS: 84DATE:
03/18/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jared Pickard, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff are not assisting resident with medications
INVESTIGATION FINDINGS:
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On 03/18/26 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent complaint visit, met with staff (ED, S1), gathered information and delivered investigation findings to ED. LPA explained the purpose of the visit with ED.

On 03/03/26 and 03/13/26, LPAs P Manalo and D Panlilio conducted interviews with reporting party (RP), resident (R1), staff (ED, S1, S2) and obtained the following documents: Personnel record (LIC500), Residents roster, R1's admission agreement, appraisals /needs & services plan, physician's report, progress notes, centrally stored medication logs, medication administration records and incident reports.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
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 5
Control Number 15-AS-20260226101220
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: DELTA SHORES ASSISTED LIVING
FACILITY NUMBER: 079201249
VISIT DATE: 03/18/2026
NARRATIVE
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Allegation: Staff are not assisting resident with medications
Investigation Finding: Substantiated
During investigation, LPAs P Manalo and D Panlilio conducted interviews with reporting party (RP), resident (R1) and facility staff (ED, S1, S2) and reviewed resident (R1) documents. On 03/03/26, LPA P Manalo interviewed RP who stated that staff were not assisting R1 with his Lovenox injections. RP stated that the injection requires two working hands, one to pinch subcutaneous fat and the other to inject the medication. RP stated R1 can only use one hand due to a weakness in his left hand. RP stated that he spoke with S1 who assured him that staff would assist R1 with the injection. However, when RP spoke with R1 again, R1 told him that he had to inject the medication himself and that staff just handed him the injection. S2 confirmed with LPA that staff only handed R1 the injection and let him administer the injection himself. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff are not assisting resident with medications was found to be substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20260226101220
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: DELTA SHORES ASSISTED LIVING
FACILITY NUMBER: 079201249
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2026
Section Cited
CCR
87468.2(a)(4)
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To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Deficiency corrected on 02/28/26.

Director of Nursing (DN) conducted in-service retraining with all Med Techs on proper procedure in assisting residents with injections.
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This requirement was not met as evidenced by staff failing to assist resident with medications which posed 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/26/2026 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20260226101220

FACILITY NAME:DELTA SHORES ASSISTED LIVINGFACILITY NUMBER:
079201249
ADMINISTRATOR:JARED PICKARDFACILITY TYPE:
740
ADDRESS:825 E 18TH STREETTELEPHONE:
(925) 706-7944
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:90CENSUS: 84DATE:
03/18/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jared Pickard, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Staff are not ensuring resident’s medical needs are met
Due to lack of supervision, resident was hit by another resident
INVESTIGATION FINDINGS:
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On 03/18/26 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent complaint visit, met with staff (ED, S1), gathered information and delivered investigation findings to ED. LPA explained the purpose of the visit with ED.

On 03/03/26 and 03/13/26, LPAs P Manalo and D Panlilio conducted interviews with reporting party (RP), resident (R1), staff (ED, S1, S2) and obtained the following documents: Personnel record (LIC500), Residents roster, R1's admission agreement, appraisals /needs & services plan, physician's report, progress notes, centrally stored medication logs, medication administration records and incident reports.

Continued on next page, LIC 9099-C pg1
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20260226101220
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: DELTA SHORES ASSISTED LIVING
FACILITY NUMBER: 079201249
VISIT DATE: 03/18/2026
NARRATIVE
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Allegation: Staff are not ensuring resident’s medical needs are met
Investigation Finding: Unsubstantiated
During investigation, LPAs P Manalo and D Panlilio conducted interviews with reporting party (RP), resident (R1) and facility staff (ED, S1, S2) and reviewed resident (R1) documents. RP stated R1 did not have a hospital bed upon admission at the facility on 02/06/26. On 03/03/26, LPA P Manalo confirmed with staff (Marketing, S2) that R1 did not have a doctor’s order for a hospital bed with rails on admission because they were waiting for Medi-Cal to complete R1’s paperwork for the transfer. RP told LPA that the facility provided R1 with the hospital bed with rails on 02/07/26. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff are not ensuring resident’s medical needs are met is unsubstantiated.

Allegation: Due to lack of supervision, resident was hit by another resident
Investigation Finding: Unsubstantiated
During investigation, LPAs P Manalo and D Panlilio conducted interviews with reporting party (RP), resident (R1) and facility staff (ED, S1, S2) and reviewed resident (R1) documents. Review of incident reports dated 02/25/26 and 03/01/26 showed R1 had an argument with another resident (R2) while eating breakfast in the dining room. R2 punched him in his right eye when R1 tried to stop R2 from grabbing his wheelchair. Both incidents showed staff redirected R1 and R2, called 911 for R1 to be evaluated and treated at the hospital. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff failed to supervise resident is unsubstantiated.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5