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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700769
Report Date: 09/19/2022
Date Signed: 09/19/2022 11:52:15 AM

Document Has Been Signed on 09/19/2022 11:52 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: DATE:
09/19/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Craig VinceletTIME COMPLETED:
11:55 AM
NARRATIVE
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On 9/19/22 at 10:15am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management for deficiencies. LPA Jensen met with care staff at the facility and was directed to 1215 W Swain Road which is the address for licensed care facility Delta at the Sherwoods. LPA Jensen met with Craig Vincelet at 1215 W Swain Road and explained the purpose of today's visit.

Community Care Licensing received an LIC 624 on 9/15/22 for a resident that signed out of the facility on 9/2/22 and did not return. LPA Jensen reviewed the submitted LIC 624 for this incident and observed the facsimile transmission to be time stamped with a date and time of 9/14/22 at 9:49am. The facsimile transmission also indicates that a phone call to number (916) 263-4700 was placed to Community Care Licensing to provide verbal notification. There is no indication on the LIC 624 indicating when the phone call to Community Care Licensing was placed. LPA Jensen requested a copy of resident 1's (R1) physician report and based on a review of this record determined that R1 can leave the community unassisted. LPA Jensen also requested a copy of the sign in and sign out log. LPA Jensen reviewed the sign in and sign out log and verified that R1 signed out on 9/2/22. Based on the records reviewed. LPA Jensen determined that the incident was not reported in writing within 7 days.

Deficiencies are being cited as a result of this case management from the California Code of Regulations, Title 22, Division 6.

An exit interview was conducted and a copy of this report, an LIC 811 along with appeal rights was given to Craig Vincelet.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2022
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 09/19/2022 11:52 AM - It Cannot Be Edited


Created By: Maja Jensen On 09/19/2022 at 11:25 AM
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: 09/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2022
Section Cited
CCR
80061(b)

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80061 Reporting Requirements
...a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event...This requirement was not met as evidenced by:
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Licensee agrees to submit a written attestation that this regulation has been read, understood and will be complied with. The attestation will be submitted via email to maja.jensen@dss.ca.gov by 5pm on 9/21/22.
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Based on a review of the LIC 624 submitted to CCLD which was received by CCLD on 9/15/22 and is time stamped with a date of 9/14/22, an incident occurred on 9/2/22 and was not reported to CCLD by 9/9/22 or within 7 days as required. This poses a potential health, safety and personal 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:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2022


LIC809 (FAS) - (06/04)
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