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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700109
Report Date: 01/30/2024
Date Signed: 01/30/2024 02:55:03 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/17/2023 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231017140117
FACILITY NAME:DELTA AT THE SHERWOODSFACILITY NUMBER:
392700109
ADMINISTRATOR:TANYA MONGEFACILITY TYPE:
740
ADDRESS:1215 W SWAIN ROADTELEPHONE:
(209) 689-3180
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:42CENSUS: 40DATE:
01/30/2024
UNANNOUNCEDTIME BEGAN:
01:47 PM
MET WITH:T MongeTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Staff threatened to restrict resident from leaving the facility premises
INVESTIGATION FINDINGS:
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 Licensing Program Analyst (LPA) Albert Johnson arrived at facility on 1/30/2024 unannounced to deliver findings for the complaint allegation listed above. LPA Johnson met with Tanya Monge and explained the purpose of today's visit.

Based on records reviewed it was confirmed that the facilities' admissions agreement has specific information for resident's disciplinary actions for various infractions. The facility provides the residents with alternatives to outings while the residents are serving their consequence from a Targeted Behavior Agreement Contract (TBAC) meeting.

Continued
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
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-20231017140117
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DELTA AT THE SHERWOODS
FACILITY NUMBER: 392700109
VISIT DATE: 01/30/2024
NARRATIVE
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The TBAC meetings are staffed by behavioral support teams, Administrator and the county if they choose to participate. R1 agreed and signed the TBAC and was placed on the restriction based on violation of the facilities policy as it relates to bullying (staff and residents), fighting and threatening harm.

The allegation is unsubstantiated. A finding of UNSUBSTANTIATED means that although the violations may have occurred as reported the preponderance of evidence standard was not met.

An exit interview was conducted and a copy of this report with appeal rights given.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2