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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700109
Report Date: 02/09/2022
Date Signed: 02/09/2022 02:52:28 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, 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
02/08/2022 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20220208113938
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: 38DATE:
02/09/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Alisha HaleTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Kitchen is unsanitary.
Food storage, preparation and service is inadequate.
INVESTIGATION FINDINGS:
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On 2/9/22 at 11:30 pm, Licensing Program Analysts (LPA's) Maja Jensen and Bruce Jacobs conducted an unannounced facility visit in regards to a complaint investigation with the above allegations. LPAs met with Med Tech Sunny Loch later Facility Manager Alisha Hale and explained the purpose of today's visit.

Throughout the course of the investigation LPA's observed the kitchen, pantry, storage areas and dining hall. LPA's observed food stored in containers that was not covered and not labeled. LPA's observed debris and food remnants on the range. LPA's observed produce with the presence of mold. LPA's observed liquid pooling on the refrigerator shelves and on the lid of a dry food storage container.

As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency(ies) cited on the LIC 9099-D, per Title 22 Regulations, Division 6.

An exit interview was conducted, and a copy of this report was provided to facility at the end of this visit.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
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 2
Control Number 27-AS-20220208113938
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/09/2022
Section Cited
CCR
87555(b)(9)
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(b) The following food service requirements shall apply:.....
(9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.
This requirement was not met as evidenced by:
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Facility agrees to read and understand CCR 87555 and submit a signed statement of understanding. Facility agrees to a deep cleaning of kitchen and food storage area. The facility manager indicated that a kitchen staff member recently ended their employment and new kitchen staff was beginning employment effective 2/10/22.
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Based upon LPA's observations the facility did not maintain sanitary conditions of the kitchen as well as safe storage and preparation of food products. LPA's observed food not properly covered. LPA's observed liquid residue at bottom of refrigerator, food particles and debris on the stove. This is a potential risk to clients in care.
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Facility agrees that kitchen staff will be trained and monitored on proper sanitation practices as well as food storage and service.
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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: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
LIC9099 (FAS) - (06/04)
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