079201249-4-30-2026-15-AS-BFOG-DTU3FF-20260506181241

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201249
Report Date: 04/30/2026
Date Signed: 04/30/2026 05:03:59 PM

Unfounded

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
04/29/2026 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20260429145308

FACILITY NAME:	DELTA SHORES ASSISTED LIVING		FACILITY NUMBER:	079201249
ADMINISTRATOR:	JARED PICKARD		FACILITY TYPE:	740
ADDRESS:	825 E 18TH STREET		TELEPHONE:	(925) 706-7944
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	90	CENSUS: 89	DATE:	04/30/2026
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Jared Pickard, Executive Director/Administrator		TIME COMPLETED:	05:40 PM

ALLEGATION(S):

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Uncleared staff provided care to residents

INVESTIGATION FINDINGS:

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On 04/30/26 at 4PM, 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 04/30/26, LPA D Panlilio conducted interviews with reporting party (RP) and staff (ED, S) and obtained the following documents: Personnel record (LIC500), S1’s fingerprint clearance documents, job application, training certifications.

Continued on next page, LIC9099-C

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20260429145308

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: 04/30/2026

NARRATIVE

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Allegation: Uncleared staff provided care to residents
Investigation Finding: Unfounded
During investigation, LPA D Panlilio conducted interviews with reporting party (RP) and facility staff (ED, S1) and reviewed staff (S1) documents. On 02/05/26, RP stated that HR staff (S1) informed her that she was fingerprint cleared in the Guardian Portal. RP stated she was hired on 02/05/26 and started working as a caregiver assisting residents with showers and activities of daily living from 02/17/26 to 04/15/26.

On 02/17/26, the facility received a notice from the California Department of Social Services (CDSS), Care Provider Management Branch (CPMB) requesting the facility to complete and submit a criminal record exemption for S1 by 04/03/26. RP stated she submitted the completed exemption requirements to HR staff (S1) on 03/21/26. RP stated she was terminated on 04/15/26 because her criminal background clearance was rescinded. Review of S1’s background clearance documentation in the Guardian Portal showed S1 was fingerprint cleared and associated to the facility when she was hired on 02/05/26 and worked at the facility from 02/17/26 until 04/15/26 . Therefore, the allegation that uncleared staff provided care to residents is unfounded.

No deficiency cited during visit. Exit interview conducted and a copy of this report provided

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026

LIC9099 (FAS) - (06/04)

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