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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700769
Report Date: 07/21/2022
Date Signed: 07/21/2022 04:58:46 PM

Document Has Been Signed on 07/21/2022 04:58 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:
07/21/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
04:09 PM
MET WITH:Tanya MongeTIME COMPLETED:
05:15 PM
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On 7-21-22 at 4:09pm, Licensing Program Analysts (LPAs) Michael Bilger and Renee Campbell arrived unannounced to conduct a health and safety check. LPAs met with facility manager on duty Tanya Monge and explained the purpose of the visit. Upon arrival LPAs observed 7 portable air conditioning units with coverage of up to 250sq ft each. Facility manager on duty stated units were purchased and delivered today. Facility has 7 shared rooms. Units were currently functioning properly during LPAs visit. LPA Bilger observed copy of work order from local heating and air conditioning company stating unit will require replacement due to age of unit. Estimated completion date for parts shipment and installation is 2-3 weeks per work order. Facility will continue to use portable units to cool facility to appropriate and comfortable temperature. Current census is 11 residents. Facility was clean and sanitary with no foul odors. Food supply was adequate. All toxins and sharp objects were inaccessible to clients in care. Three staff members were present during LPAs visit.

No deficiencies observed today. An exit interview was conducted with Tanya Monge and a copy of this report was left with Tanya.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2022
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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