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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700109
Report Date: 12/09/2021
Date Signed: 12/10/2021 05:51:44 AM

Document Has Been Signed on 12/10/2021 05:51 AM - 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 SHERWOODSFACILITY NUMBER:
392700109
ADMINISTRATOR:LEAH ZUBIATEFACILITY TYPE:
740
ADDRESS:1215 W SWAIN ROADTELEPHONE:
(209) 689-3180
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 42CENSUS: 37DATE:
12/09/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Susan Lo, Residential Service ManagerTIME COMPLETED:
10:15 AM
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LPA Bruce Jacobs received an incident report from the facility and conducted a follow-up investigation. Licensing received a report of a death of a resident in the care home and the cause of the death was not known. The resident was found unresponsive in the home and paramedics were call and responded. The EMTs performed CPR on the resident for a period of time and then pronounced the resident deceased. A death certificate has not been received by the facility. Facility has agreed to provide CCL with the death certificate of reported cause of death when known. The resident (R-1) was 85 years old at the time of the death. Interviews were conducted and the resident's file was reviewed.

LPA determined after interviews and a review of the client's record, that was not sufficient information to prove with a preponderance of evidence that a deficiency occurred or was identified and issued on this visit.

Exit interview conducted and report issued.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
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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