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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700769
Report Date: 04/24/2024
Date Signed: 04/24/2024 03:34:33 PM

Document Has Been Signed on 04/24/2024 03:34 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DELTA MANORFACILITY NUMBER:
392700769
ADMINISTRATOR/
DIRECTOR:		VINCELET, CRAIGFACILITY TYPE:
735
ADDRESS:1201 W. SWAIN ROADTELEPHONE:
(805) 242-0135
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 14CENSUS: 13DATE:
04/24/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Shawn Flanagan and Farina KhanTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On 4/24/2024, Licensing Program Analyst (LPA) Albert Johnson arrived to the facility and met with Shawn Flanagan and Farina Khan to follow -up on requested information from 4/22/2024. Later Joined by Leah Zubiate.

During the visit on 4/22/2024, the department requested information for staff including personnel files and other information for Staff S1, S2 and S3's Personnel Records (LIC501), training's, Mandated Reporter Forms, any staff write-ups: positive or negative, and employment applications. The facility submitted information for one staff (S1), however the above requested information was not sent by close of business on 4/23/2024 for the other two(S2 and S3). Today, the facility will provide the requested information at the close of this visit.

The facility did not have the records available for review as required by 80066(e)(1) personnel records and 80044(A)(b1)(c1) inspection authority.

As a result of this visit, deficiencies will be cited on 809-D, per Title 22 Regulations, Division 6.

Exit interview with Staff

Appeals rights printed.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/24/2024 03:34 PM - It Cannot Be Edited


Created By: Albert Johnson On 04/24/2024 at 10:48 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DELTA MANOR
FACILITY NUMBER: 392700769

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
05/02/2024
Section Cited
CCR
80066(e)(1)

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80066 Personnel Records(e) All personnel records shall be maintained at the facility site and shall be available to the licensing agency for review.

(1) The licensee shall be permitted to retain such records in a central administrative location provided that they are readily available to the licensing agency at the facility site as specified in Section 80066(c).
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The facility will amend there program design to include the use of electronic files for staff and residents if this is the method to be used by the facility for evaluations, inspection or other business related to the licensed facility.
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This requirement was not met as evidenced by the department inability to review the documents according to the regulatory requirement cited in this report.
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The plan will be submitted by POC date 5/2/2024
Deficiency Dismissed
Type B
05/02/2024
Section Cited
CCR80044(A)(b1)(c1)

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Inspection Authority of the Licensing Agency(a) The licensing agency shall have the inspection authority specified in Health and Safety Code Sections 1526.5, 1533, 1534, 1538, and 1538.7.
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The facility will amend there program design to include the use of electronic files for staff and residents if this is the method to be used by the facility for evaluations, inspection or other business related to the licensed facility.
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(b) The licensing agency shall have the authority to interview clients, including children, or staff members, without prior consent.
(1) The licensee shall ensure that provisions are made for private interviews with any clients, including children, or any staff members. (c) The licensing agency shall have the authority to inspect, audit, and copy client or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements specified in Sections 80066(c) and 80070(d). (1) The licensee shall ensure that provisions are made for the examination of all records relating to the operation of the facility. This requirement was not met as evidenced by the department inability to review the documents according to the regulatory requirement cited in this report.
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The plan will be submitted by POC date 5/2/2024
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:Lisa Rios
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024


LIC809 (FAS) - (06/04)
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