<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700109
Report Date: 09/27/2021
Date Signed: 09/27/2021 11:00:37 AM

Document Has Been Signed on 09/27/2021 11:00 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:DELTA AT THE SHERWOODSFACILITY NUMBER:
392700109
ADMINISTRATOR:LEAH ZUBIATEFACILITY TYPE:
740
ADDRESS:1215 W SWAIN ROADTELEPHONE:
(209) 689-3180
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 42CENSUS: 37DATE:
09/27/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Richard EspinozaTIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 09/27/2021 at 8:30am, Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a case management visit to follow up on incident reports submitted to the Department. LPA contacted Administrator for COVID screening prior to today's visit who confirmed no staff or residents have tested positive within the past 10 days for COVID. LPA arrived, met with Designated staff one (S1), explained the purpose of today’s visit, and was was allowed entry into the facility. Current census 37.

LPA received incident report for incident of altercation between Resident one (R1) and Resident two (R2). Staff two (S2) responded immediately and assessed R1 for injury, contacted Local Law enforcement and responsible parties were notified. R1 declined hospital treatment, follow up with primary care physician scheduled.

LPA conducted a case management inspection to ensure proactive measures were put in place to prevent further incidents. If there is another reoccurrence of the same nature the department will require residents be reassessed by their physician to determine if the current placement continues to be appropriate.

Per the California Code of Regulations, Title 22, Division 6, no deficiencies observed or cited. Exit interview held and a copy of report provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2021
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 1