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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700769
Report Date: 04/09/2024
Date Signed: 04/29/2024 03:09:32 PM

Document Has Been Signed on 04/29/2024 03:09 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:
04/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:06 AM
MET WITH:Sean Flanigan/ Fraina KhanTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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On 4/9/2024 Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced annual visit on this date. LPA met with S. Flanigan and explained the purpose of the visit. LPA was later joined by F. Khan and Essence Moore.

The facility is a single story structure with wheelchair accessibility. LPA observed all required signage, including license to be prominently posted. LPA toured the facility indoors and outdoors including but not limited to dining room, living room, kitchen, covered garage/ smoking area, 3 bathrooms, 7 bedrooms and backyard. The facility is licensed for 14 clients.

Hot water temperature was measured at 112 degrees Fahrenheit in resident's bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguishers are current and in compliance with fire safety. Fire drill was conducted on 7/6/2021, out of compliance. Carbon dioxide monitor present. Smoke detector in zone 4 in the men's restroom area needs service, as it continues to beep. LPA reviewed 10 resident and 5 staff files, including criminal record clearances. All staff today are associated to the facility. First aid kit was checked and is complete.

Deficiencies were cited as a result of today's visit. An exit interview was conducted and a report was left with the facility with appeal rights
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
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 04/29/2024 03:09 PM - It Cannot Be Edited


Created By: Albert Johnson On 04/09/2024 at 12:35 PM
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: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
80023
Fire clearance

This requirement is not met as evidenced by: Smoke dectector in the men restroom in zone 4 is in need of service it is beeping.
Deficient Practice Statement
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Based on observation and testing the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.1
POC Due Date: 04/10/2024
Plan of Correction
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The licensee will replace or repair the smoke detector in the men's bathroom (zone 4) by POC date 4/10/2024
Request Denied
Type A
Section Cited
HSC
1531.2
(h) fire and earthquake drill...

This requirement is not met as evidenced by:
Records reviewed and interviews with staff confirmed that the facility has not conducted a drill since 7/6/2021.
Deficient Practice Statement
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Based on interview and records review, the licensee did not comply with the section cited above. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2024
Plan of Correction
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The facility conducted a drill today and will document it according to the scenario for the drill.
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: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024


LIC809 (FAS) - (06/04)
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