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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700109
Report Date: 11/24/2021
Date Signed: 11/24/2021 10:44:39 AM

Document Has Been Signed on 11/24/2021 10:44 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:
11/24/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Susan Lo, Residential Service SupervisorTIME COMPLETED:
10:55 AM
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LPA Bruce Jacobs received an incident report from the facility and conducted a follow-up/investigation. Licensing received an report of an altercation between tow clients with the initial report indicating one client (C-1) was the aggressor. During a follow-up review of the incident by this LPA ,information was obtained that the aggressor was taken into custody and recently released back to the facility. The other client (C-2) was treated for minor injuries at the ER and returned to the facility. Staff was in the vicinity at the time of the altercation and intervened. Law Enforcement was contacted and the other client was treated for minor injuries.

LPA interviewed the staff involved in the incident who provided additional information. The client (C-1) has not been compliant for medication for his mental health diagnosis for several months. The facility is working to get the client back on his meds and will consult with their psychiatrist to discuss other medications options if unsuccessful. At this time the client is reported to be stable. The client (C-1) has been verbally, but not physically aggressive in the past.

LPA determined after interviews and a review of the client's record, that was not sufficient information to prove with a preponderance of evidence that a deficiency occurred or was identified and issued on this visit.

Exit interview conducted and report issued.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/24/2021
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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