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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700109
Report Date: 09/27/2021
Date Signed: 09/27/2021 11:00:06 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:POCUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Richard EspinozaTIME COMPLETED:
11:00 AM
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On 09/27/2021 at 8:30am, Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a case management visit to clear POC's. 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.

Deficiency cited under Title 22 87303(a) has been completed by the extended POC due date including repair work in resident common shower for one of three showers with water damage pulling off the wall, dried leaves and brush, broken gutters, dryer vent dust debris, overgrown trees, and cigarette butts on property grounds not maintained to be completed by 9/3/2021. LPA observed fenced off area to rear of property making areas of Copenhagen Hall, gazebo, and storage shed inaccessible with "No Trespassing" signs posted. S1 stated all repair work completed and plans for preventative maintenance are in place with staff and gardener service. LPA observed shower work repairs completed however caulking in one area pulling up, S1 ordered work service request to repair caulking in the area.

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)
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