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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700109
Report Date: 03/19/2024
Date Signed: 03/19/2024 02:49:43 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
01/12/2024 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240112115446
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: DATE:
03/19/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Tanya MongueTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff will not allow resident to have a bike
INVESTIGATION FINDINGS:
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On 3/19/2024, LPA Johnson arrived unannounced to deliver finding for the above listed allegations.

Allegation: Staff will not allow resident to have a bike. Based on review of the admissions agreement and program design the facility is following the plan to ensure that the residents in care are safe, free from harm, danger and potential accusations.

R1's physician's report does not restrict him from having a bike, however, the bike in question was given to R1 by someone in the community. The origin of how the bike was given to R1 is the question that the facility is attempting to figure out.
Continued
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
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 4
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
01/12/2024 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240112115446

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: DATE:
03/19/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Tanya MongueTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff inappropriately took resident's personal belongings
INVESTIGATION FINDINGS:
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Allegation: Staff inappropriately took resident's personal belongings. Based on interviews with the residents and records reviewed the facility is required to have all toxins locked and inaccessible to residents. The facility confirmed that R1's physician's report does not allow for R1 to hold items that may be hazardous to the health and safety of R1 or R1's roommate. However, R1 is allowed to hold his personal hygiene items. The items removed from R1's room are considered toxins and if ingested would cause harm beyond basic first aid or death. 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.

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

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20240112115446
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: 03/19/2024
NARRATIVE
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The program states that R1 has a history of taking items that is not his and attempting to sell these items. The facility has not had a police visit or inquiry as it relates to the bike and how R1 may have obtained the bike.

Although the facility in good faith is attempting to prevent R1 from the ill effects of what may be. There is no doctor's objection to R1 having a bike, no rule established by the facility or regulation to support R1 not having a bike.

The allegation is substantiated.

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: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20240112115446
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: 03/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2024
Section Cited
CCR
87468.2(a)(3)
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87468.2 (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
. (3) To be encouraged and assisted in exercising their rights as citizens and as residents of the facility. Residents shall be free from interference, coercion, discrimination, and retaliation in exercising their rights.
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The facility will review the policy for personal property and include what may or may not be stored at the facility including modes of transportation etc.
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This requirement is not met as evidenced by records reviewed and interviews conducted. The bike is not at the facility and is not list on R1 personal property inventory sheet.

This is a personal right violation
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 The addendum to the program plan will be provided to the department by close of business on POC date 3/29/24.
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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: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4