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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700109
Report Date: 03/07/2024
Date Signed: 03/07/2024 12:41:48 PM

Substantiated


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
02/28/2024 and conducted by Evaluator Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20240228151709
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: 38DATE:
03/07/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tanya Monge, AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility staff are not assisting residents with hygiene needs after digging through the trash
INVESTIGATION FINDINGS:
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On 03/07/2024 at 09:00 AM, Licensing Program Analyst (LPA) Renee Campbell and Licensing Program Manager (LPM) Lisa Rios conducted an unannounced facility visit to open a complaint investigation. Upon entry, LPA Campbell and LPM Rios met with S1 and S2 and explained the purpose of today's visit.

LPA and LPM toured the facility with S2 and met with S3 while on tour of the kitchen. Administrator Tanya Monge arrived at 10 am and arranged interviews with R1, R2, R6 and R7. Over the course of the investigation based on interviews with 4 residents, it was disclosed that 2 to 3 residents dig through the trash at meal time and start eating the food. Staff discourage residents from eating from the trash but 4 out of 4 residents state that they are not reminded to wash their hands after digging in the trash.

Based on interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
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 3
Control Number 27-AS-20240228151709
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: 03/07/2024
NARRATIVE
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Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, a deficiency is being cited on the attached 9099D during this visit.

If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed.
A copy of their rights was provided (LIC9058) and their signature on this form acknowledges receipt of these rights.

An exit interview was conducted, and a copy of this report was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20240228151709
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
03/15/2024
Section Cited
CCR
87101(c)(3)A)
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87101(c)(3)(A) Definition "Care and Supervision" means those activities which if provided shall require the facility to be licensed.(A) Assistance in dressing, grooming, bathing and other personal hygiene;
This requirement is not met:
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Administrator will meet with staff to remind them to ensure client’s to ask for more food if they are still hungry and to urge client's to wash their hands when digging in the class. A sign in sheet will be emailed to LPA Campbell at renee.campbell@dss.ca.gov to verify the meeting..
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Based on 4 out of 4 interviews, staff are not reminding nor assisting residents with hand washing after residents are digging through the trash at meal time.

This poses a potential Health, Safety or personal rights risk to persons in care.
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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: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3