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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700109
Report Date: 06/08/2022
Date Signed: 06/08/2022 04:02:30 PM

Document Has Been Signed on 06/08/2022 04:02 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: 30DATE:
06/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Tanya MongeTIME COMPLETED:
04:15 PM
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On 6/8/22 Licensing Program Analyst (LPA) Maja Jensen arrived at the facility arrived unannounced to conduct a required one year annual visit. LPA Jensen met with resident care coordinator Tanya Monge and explained the purpose of today's visit.

The facility is a single story building with one central entry point designated for universal screening and a sign in policy has been enacted to ensure compliance. The central entry point was observed to be equipped with sanitizer and appropriate infection control signage was posted throughout the facility. Additional 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 Jensen toured the facility including but not limited to common areas, dining hall, kitchen, pantry, administrative offices, 6 resident rooms and grounds. During the course of the visit LPA Jensen engaged with several residents in care.

The kitchen was observed to be clean and sanitary. 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 refrigerator was maintained at 37 degrees and the freezer was 0 degrees which is in compliance with regulations. A regular deep cleaning schedule is maintained for the kitchen through an outside vendor.

The fire alarm and carbon monoxide detector was checked and observed to be in good working order. The fire extinguishers were last serviced on July 28, 2021 and are in compliance. Adequate lighting was observed throughout the facility. The facility temperature was set at 75 degrees which halls within the required range of 68-85 degrees.

Continued on 809C.....
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 06/08/2022
NARRATIVE
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The facility operates with delayed egress door system. The resident rooms are divided in to men's and women's halls. A resident room in the men's hall was observed to have a sink that was visibly detaching from the wall-see 812 for room number. The sink in that was detaching from hall had only cold water. The same resident room was observed to have broken glass in the window sill. Two blue colored upholstered chairs in the atrium next to the exit doors were observed to have large stains on the cushions. A door in a resident room leading to the bathroom was observed to be damaged. The signal system in the resident rooms consists of pull cords that when activated send a signal to the medications room. The signal system was observed to be non-functional in a resident room. Water temperature in common area bathrooms measured at 110 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. The facility maintains an adequate supply of PPE.

Staff roster was reviewed and all staff were verified as having obtained a California clearance or a criminal record exemption as required by law.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 809D during this visit. The Licensee was provided a copy of their appeal rights. Exit interview held and a copy of report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
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Document Has Been Signed on 06/08/2022 04:02 PM - It Cannot Be Edited


Created By: Maja Jensen On 06/08/2022 at 02:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's observation of a resident room that contained a sink separating from the wall, the lack of hot water at the sink separating from the wall, broken glass in the window sill of a resident room, a damaged door in a resident room and stained upholstered chairs in the atrium. This poses a potential health and safety threat to residents in care.
POC Due Date: 06/22/2022
Plan of Correction
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Licensee agrees to remove the broken glass from the window sill, replace or repair the damaged sink and door. The Licensee also agrees to clean or replace the stained upholstered chairs in the atrium. Proof of correction will include photos and/or receipts to be mailed to Community Care Licensing at maja.jensen@dss.ca.gov by the POC due date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/08/2022 04:02 PM - It Cannot Be Edited


Created By: Maja Jensen On 06/08/2022 at 02:49 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(i)(1)(A-C)
Facilities shall have signal systems which shall meet the following criteria:

(1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:

(A) Operate from each resident's living unit.
(B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.
(C) Identify the specific resident living unit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's test of the signal system in a resident room in the men's hall, the pull cord was determined to be non-functional. This poses a potential health and safety risk to resident in care.
POC Due Date: 06/15/2022
Plan of Correction
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The Licensee agrees to conduct an evaluation of the functionality of the signal system in every resident room and to replace or repair any non-functional systems. The Licensee also agrees to implement a regularly scheduled check of the operation of the signal system with a frequency of no less than once a month. The Licensee will submit proof of correction to maja.jensen@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022


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