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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700769
Report Date: 07/20/2022
Date Signed: 07/20/2022 04:35:30 PM

Document Has Been Signed on 07/20/2022 04:35 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 MANORFACILITY NUMBER:
392700769
ADMINISTRATOR:ZUBIATE, LEAHFACILITY TYPE:
735
ADDRESS:1201 W. SWAIN ROADTELEPHONE:
(805) 242-0135
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 14CENSUS: 11DATE:
07/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Tanya MongeTIME COMPLETED:
04:45 PM
NARRATIVE
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On 7-20-22 at 3:50pm, Licensing Program Analysts (LPAs) Michael Bilger and Renee Campbell arrived unannounced to conduct a case management related to health and safety checks based on an earlier visit. LPAs met with facility manager Tanya Monge and explained the purpose of the visit. Upon arrival at 1201 W Swain Rd at 1:30pm, LPAs rang door bell and was greeted by resident (R1) of the facility. LPAs did not observe staff on duty at this time. LPAs arrived at adjacent facility at 1215 W Swain Rd at approximately 1:35pm and was greeted by theraputic program coordinator (TPC), staff1 (S1) who stated he was the sole staff member at facility on 1201 W Swain Rd. S2 also greeted LPAs upon arrival at 1215 W Swain Rd, and confirmed S1 was the sole staff member at 1201 W Swain Rd. LPAs arrived back at 1201 W Swain Rd at approximately 1:40pm. During LPAs visit, facility manager confirmed S1 was the sole staff member at 1201 W Swain Rd. Based on observation and interviews, it was determined that S1 was not providing care and supervision at 1201 W Swain Rd for approximately 10 minutes.

As a result of today's visit, deficiencies are cited under Title 22, Division 6. An immediate civil penalty of $500 is assessed in addition to citation issued. An exit interview was conducted with Tanya Monge and a copy of this report was left with Tanya. Appeal Rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2022
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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Document Has Been Signed on 07/20/2022 04:35 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Michael Bilger On 07/20/2022 at 04:16 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 MANOR
FACILITY NUMBER: 392700769

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
07/21/2022
Section Cited
CCR
80078(a)

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80078 Responsiblity of provding care and supervision. (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by:
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Licensee will submit a plan ensuring 24/7 care and supervision and avoiding residents left alone. Plan to be submitted by POC due date.

Licensee will read regulation 80078(a) and submit a signed statement of understanding to LPA by POC due date.
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Based on interviews and observation, it was determined that Licensee did not ensure proper care and supervision for residents in care. S1 was sole staff member and left facility for approximately 10 minutes on 7-20-22. This poses and immediate health, safety and resident rights risk to residents in care.
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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:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022


LIC809 (FAS) - (06/04)
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