392700109-6-27-2023-27-AS-RWAE-CT7UJY-20230627153818

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700109
Report Date: 06/27/2023
Date Signed: 06/27/2023 03:38:28 PM

Document Has Been Signed on 06/27/2023 03:38 PM - 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 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: 37	DATE:	06/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Craig Vincelet - Administrator		TIME COMPLETED:	04:00 PM

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	Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced required one year annual visit. LPA met with administrator and explained the purpose of today's visit. The facility is a single story building with signage including but not limited to See Something Say Something, Fire clearance, disaster plan, employee rights and resident rights was observed to be posted in prominent areas and visible to staff and residents. LPA and administrator toured the facility including but not limited to common areas, dining hall, kitchen, pantry, administrative offices, resident rooms, and grounds. The kitchen was observed to not be clean and sanitary on the floor behind dishwasher. A seven day supply of non-perishable food and 2 day supply perishable food was observed. A weekly menu was posted in a prominent area visible by residents. The fire alarm and carbon monoxide detector was checked and observed to be in good working order. The fire extinguishers were last serviced on 9/24/2022 and are in compliance. Adequate lighting was observed throughout the facility. The facility temperature was set at 73 degrees which halls within the required range of 68-85 degrees. The facility operates with delayed egress door system. The resident rooms are divided in to men's and women's halls. Water temperature in common area bathrooms measured at 109.4F degrees which falls within the required range of 105 to 120 degrees. The facility maintains medication in a locked storage room that is inaccessible to residents. Toxins, disinfectants and sharp objects were observed to be stored in locked areas and are inaccessible to residents. The grounds were observed to be clean and in free of obstruction. Continued on 809-C Page 2

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/27/2023

NARRATIVE

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Continued from 809 - Page 2

LPA reviewed 4 staff record files and the facility has sufficient staffing to provide the services needed to meet the residents’ needs. All staff have criminal record clearance and are associated to the facility. LPA reviewed 5 resident files which had all required documents.

LPA received the following updated documents for Community Care Licensing: LIC 308 Designation of Administrative Responsibility, Administrator’s Certificate and Liability Insurance

Deficiency was cleared during LPA visit and area behind dishwasher was cleaned.

Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 809-D during this visit.

Exit interview held with administrator. A copy of reports and appeal rights were provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 06/27/2023 03:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(27)

General Food Service Requirements

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation there was a couple of inches of dirt, debris, and grime behind dishwasher, the licensee did not comply with the section cited above in licensee did not have kitchen area behind dishwasher clean which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/29/2023
	Plan of Correction
1 2 3 4	Licensee agrees to have area behind dishwasher deep cleaned at least monthly and as needed by POC date of 6/29/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

LIC809 (FAS) - (06/04)

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