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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700769
Report Date: 09/29/2022
Date Signed: 09/29/2022 12:57:42 PM

Document Has Been Signed on 09/29/2022 12:57 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: 10DATE:
09/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Craig VinceletTIME COMPLETED:
01:00 PM
NARRATIVE
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On 9/29/22 at approximately 10am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management for deficiencies relating to an expired Administrator's certificate. LPA Jensen met with assistant administrator Craig Vincelet and explained the purpose of today's visit.

The Administrator for the facility is currently listed as Leah Zubiate. The Administrator's Certificate for Leah Zubiate has expired. The Community Care Licensing Division Administrator Certification Section confirmed that an Administrator's Certificate renewal request was sent by Leah Zubiate on 1/8/21. On 3/29/21 the Community Care Licensing Division Administrator Certification Section sent notification of incomplete documentation for the renewal. The application was withdrawn due to a lack of response. On 7/12/22 LPA Jensen sent Administrator Leah Zubiate the phone number and email for the Department's Administrator Certification division so she could address the expired certification. The Community Care Licensing Department has not received any notification of a change in Administrators to date.

Deficiencies are being cited from the California Code of Regulations, Title 22, Division 6.

An exit interview was conducted and a copy of this report and appeal rights were given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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 09/29/2022 12:57 PM - It Cannot Be Edited


Created By: Maja Jensen On 09/29/2022 at 09:12 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: 09/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2022
Section Cited
CCR
85064(b)

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85064 Adminstrator Qualifications and Duties
...
(b) All adult residential facilities shall have a certified administrator. This requirement was not met as evidenced by:
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The Licensee agrees to appoint a new Administrator of record to the facility. An email was sent to LPA Jensen during the course of the visit notifying the Department of the intent to appoint a new Administrator. LPA Jensen requested a letter from the licensee appointing the individual as the Administrator, an LIC 308, a copy of the current Aministrator's certificate, an LIC 200, an LIC 500 and an LIC 501 to be faxed to the Department by close of business on 10/3/22.
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Based on LPA Jesen's verification with Community Care Licensing Division
Administrator Certification Section, Administrator Leah Zubiate does not hold a current Administrator's Certificate. 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: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022


LIC809 (FAS) - (06/04)
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