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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700769
Report Date: 11/18/2022
Date Signed: 11/30/2022 11:55:01 AM

Document Has Been Signed on 11/30/2022 11:55 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:
11/18/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Craig VinceletTIME COMPLETED:
12:30 PM
NARRATIVE
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****This document is amended only to correct a spelling of a name and an erroneous date given for a Plan of Correction. The new Plan of Correction due date allows for the same amount of time to complete the Plan of Correction.*****

On 11/18/22 at 10:40 am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management for deficiencies. LPA Jensen met with Craig Vincelet and explained the purpose of today's visit.

The Administrator's certificate for Leah Zubiate expired in the year 2021. On 9/29/22 LPA Jensen cited the facility for not having an Administrator with a current Administrator's certificate and the Licensee agreed to a Plan of Correction with a due date of 10/03/22. The Licensee submitted documentation and Leah Zubiate, the Administrator of record who's certification has expired, was advised by LPA Jensen that the documentation is incomplete and/or incorrect on 10/20/22. LPA Jensen advised Leah Zubiate again on 11/1/22 that the documentation requested is incomplete and/or incorrect and past due. LPA Jensen advised Leah Zubiate again on 11/4/22 that the documentation is incomplete and/or incorrect.


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

An exit interview was conducted and a copy of this report and appeal rights was given to Craig Vincelet

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2022
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 11/30/2022 11:56 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/28/2022 08:57 AM


Created By: Maja Jensen On 11/18/2022 at 09:32 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DELTA MANOR
FACILITY NUMBER: 392700769

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
12/02/2022
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 currently certified Administrator of record to the facility. 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 emailed to maja.jensen@dss.ca.gov by close of business on Plan of Correction due date.
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Based on LPA Jensen's verification that the Administrator of record is not currently certified and the Licensee did not submit complete and/or correct documentation to appoint a qualified and currently certified Administrator as requested on more than 3 separate occassions. 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: 11/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022


LIC809 (FAS) - (06/04)
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