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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700769
Report Date: 12/09/2021
Date Signed: 12/09/2021 10:08:24 AM

Document Has Been Signed on 12/09/2021 10:08 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 MANORFACILITY NUMBER:
392700769
ADMINISTRATOR:ZUBIATE, LEAHFACILITY TYPE:
735
ADDRESS:1201 W. SWAIN ROADTELEPHONE:
(805) 242-0135
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 14CENSUS: 11DATE:
12/09/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Alisha HaleTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Bruce Jacobs, conducted an unannounced case management visit to follow up on an open complaint and pending audit. LPA met with Alisha Hale and Susan Lo, Residential Services Manager and discussed the purpose of the visit.
The purpose of this visit is the Department is conducting a financial audit as a result of an open complaint where additional information was found regarding possible violations of personal rights. The Licensee and/or Licensee Representative for the facility is to provide to the Department all of the following listed documents by 12/30/2021:
· P&I Logs for all facilities January 2021 – Current (Due to the volume this request will only cover this year) – Should an exception be noted further documentation for the exception may be needed.
· All Wealth Wagon Cards sold for all facilities April 2020 – Current
· P&I ledgers for all clients who P&I is being held for, April 2020 - Current
· Status of where all P&I funds are kept – if in a financial institution – Bank statements for April 2020 – Current
· Cash handling policy and procedures
· Copy of Bond for all facilities

This information is used for the purpose of auditing and regulating Community Care Facilities and Residential Care Facilities for the Elderly.
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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