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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700109
Report Date: 02/09/2022
Date Signed: 02/09/2022 02:53:15 PM

Document Has Been Signed on 02/09/2022 02:53 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 SHERWOODSFACILITY NUMBER:
392700109
ADMINISTRATOR:LEAH ZUBIATEFACILITY TYPE:
740
ADDRESS:1215 W SWAIN ROADTELEPHONE:
(209) 689-3180
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 42CENSUS: 38DATE:
02/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Alisha Hale, Facility ManagerTIME COMPLETED:
03:10 PM
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LPAs Bruce Jacobs and Maja Jensen conducted an unannounced case management visit at the facility and met with Facility Manager Alisha Hale for follow-up on a report of a resident's leaving the facility without permission. The case management visit was conducted by LPA Jacobs and Jensen and consisted of reviews of the facility records and interviews with facility management.

The facility management were contacted/interviewed by LPA Jacobs. Information obtained from interviews and record reviews document the resident was under supervision and left the facility against the directions of facility staff. A missing persons report was filed with Law Enforcement and an Incident Report was submitted to the Department. The resident's (R-1) Physician's Report (LIC 602) documents that the resident is able to leave the facility unassisted.

Based on all interviews and observations, the resident was able to leave the facility unassisted and this was determined to be a behavior and not inadequate supervision. No deficiencies were identified.

Report provided during exit interview.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2022
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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