392700109-1-26-2024-27-AS-KHOS-D2ELFP-20240213074329

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700109
Report Date: 01/26/2024
Date Signed: 01/26/2024 12:23:56 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
10/11/2023 and conducted by Evaluator Albert Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20231011123255

FACILITY NAME:	DELTA AT THE SHERWOODS		FACILITY NUMBER:	392700109
ADMINISTRATOR:	TANYA MONGE		FACILITY TYPE:	740
ADDRESS:	1215 W SWAIN ROAD		TELEPHONE:	(209) 689-3180
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95207
CAPACITY:	42	CENSUS: 40	DATE:	01/26/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Tanya Monge		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff is not providing resident access to their money.
Staff withhold food from residents.
The facility has mold.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Albert Johnson arrived at facility on 1/26/2024 unannounced to deliver findings for the complaint allegations in to the above list. LPA Johnson met with Tanya Monge and explained the purpose of today's visit.

Allegation: Staff is not providing resident access to their money. Based on records reviewed it was confirmed that the facility uses a payee service for the Residents in care.
The information is outlined in the admissions agreement with specific instructions for disbursements of funds, deposit of funds and how the residents will receive personal and incidentals funds. The facility uses form LIC 405(Record Of Client's/Resident's Safeguarded Cash Resources) for tracking of funds that have been sent over by the facilities corporate head quarters. The allegation is unsubstantiated.

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20231011123255

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: 01/26/2024

NARRATIVE

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Allegation: Staff withhold food from residents. Based on interviews with the residents and observation on 10/12/2023, 10/25/2023, and 11/27/2023 the facility provides three meals and snack at specific times through out the day. The residents interviewed denied having food taken away by staff, however they did mention that there is a resident that will take food from them and the staff will have to intervene and redirect the resident and return or replace the food that was taken. The allegation is unsubstantiated.

Allegation: Facility has mold. Based on observation, records reviewed and interviews with outside agencies the facility appears not to have/had a problem with mold in or around the facility. The facility provided the department with work orders and receipts for the repair work completed at the facility in the residents shower. LPA observed the work in progress and being completed on 10/12/2023, 10/25/2023, 11/27/2023 and again on 1/26/2024. The facility denies that the presence of mold was present at the time of the first repair and continues to deny that there was mold at anytime. 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.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC9099 (FAS) - (06/04)

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