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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700109
Report Date: 10/14/2021
Date Signed: 10/14/2021 03:01:28 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/27/2021 and conducted by Evaluator Ashley Boothe
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210727082534
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: 34DATE:
10/14/2021
UNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Richard EspinozaTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff severely neglected resident while in care
Staff failed to follow resident's dietary plan.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/14/2021 at 2:25pm, Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to deliver the findings of complaint investigation with the following allegations: #1 staff severely neglected resident while in care and # 2 staff failed to follow resident's dietary plan. LPA met with Administrator and explained the purpose of today’s visit. LPA was allowed entry into the facility, current census is 34.

During the course of the investigation the Department conducted on site inspection, reviewed records, conducted interviews, and conducted a collateral visit on 10/6/2021 to a licensed care facility to interview residents and staff.

Continued on 9099 C.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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 4
Control Number 27-AS-20210727082534
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 SHERWOODS
FACILITY NUMBER: 392700109
VISIT DATE: 10/14/2021
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
26
27
28
29
30
31
32
Continued on from 9099.

#1 Staff severely neglected resident while in care
Interviews concluded no incidents of severe neglect in care. Staff monitor residents regularly for changes in condition and use daily logs to document shift turnover and residents conditions. Records reviewed updated care plans according to medical assessments. Interviews conclude no residents reported instances of severe neglect in care. Resident one (R1) and R1's responsible party did not report neglect in care for R1. Staff one (S1) and Staff two (S2) reported no instances of observing residents with severe neglect.

# 2 Staff failed to follow resident's dietary plan
LPA observed residents on special diets to be posted in kitchen linear with medical assessments. Interviews conclude residents on special diets are encouraged to make choices while picking snacks and options are available to meet residents special diet conditions. R1 was not prescribed a special diet per physician's order.

It was determined in the course of the investigation based on the information provided through documentation and interview, the aforementioned allegations are unfounded. This agency has investigated the complaint alleging the facility and we have found the allegations false.

Per California Code of Regulations (CCRs) - Title 22, Division 6, no deficiencies are being cited. Exit interview held, copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/27/2021 and conducted by Evaluator Ashley Boothe
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210727082534

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: 34DATE:
10/14/2021
UNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Richard EspinozaTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff failed to meet resident's medical needs
Staff failed to meet resident's hygiene needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/14/2021 at 2:25pm, Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to deliver the findings of complaint investigation with the following allegations: #1 staff failed to meet resident's medical needs and #2 staff failed to meet resident's hygiene needs. LPA met with Administrator and explained the purpose of today’s visit. LPA was allowed entry into the facility, current census is 34.

During the course of the investigation the Department conducted on site inspection, reviewed records, conducted interviews, and conducted a collateral visit on 10/6/2021 to a licensed care facility to interview residents and staff.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20210727082534
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 SHERWOODS
FACILITY NUMBER: 392700109
VISIT DATE: 10/14/2021
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
26
27
28
29
30
31
32
Continued from 9099A.

(#1) LPA observed staff use outlook calendar to coordinate medical appointments. Residents reoccurring appointments are coordinated and staff make appointments based on needs and services. R1's physician ordered blood work, resulted critical, and R1 was transported by emergency medical transport to hospital and admitted. Resident two (R2) was observed to be provided assistance immediately upon request for Crisis. Resident three (R3) stated they had not seen a dentist in two years and wanted to go. LPA observed dental appointments on calendar but none scheduled for R3 during records review and it was unclear if R3 had asked to go or whether delay was due to COVID precautions of dental offices closures.

(#2) LPA observed residents to be bathed, groomed, wearing clothing free of spills and debris and no body odor. The house rules state residents need to maintain hygiene and shower at least twice weekly. Interviews conclude residents are provided verbal prompting for reminders and provided assistance as necessary. R1's responsible party reported staff are "not heavy on verbal prompting" for R1 who requires prompting for bathing teeth brushing. Staff one (S1) stated toothbrushes are changed monthly or more often as needed. R1 reported not brushing teeth. R1 requested shave and it is unclear is R1 requested trim or full shave as observed with facial hair.

It was determined in the course of the investigation based on the information provided through documentation and interview, the aforementioned allegations are unsubstantiated. A finding that the allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Per California Code of Regulations (CCRs) - Title 22, Division 6, no deficiencies are being cited. Exit interview held, copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4