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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700769
Report Date: 12/05/2024
Date Signed: 12/05/2024 10:28:47 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/06/2024 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240806134043
FACILITY NAME:DELTA MANORFACILITY NUMBER:
392700769
ADMINISTRATOR:VINCELET, CRAIGFACILITY TYPE:
735
ADDRESS:1201 W. SWAIN ROADTELEPHONE:
(805) 242-0135
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:14CENSUS: 12DATE:
12/05/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:F. KhanTIME COMPLETED:
02:16 PM
ALLEGATION(S):
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9
The facility is over-charging SSI Clients
Responsible party did not sign the Admissions Agreement
The facility is using residents' SSI / P&I funds for payment of basic services
INVESTIGATION FINDINGS:
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2
3
4
5
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9
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12
13
On 12/05/24, LPA Johnson arrived unannounced to deliver finding for the above allegations. LPA met with Staff and was later joined by the Administrator.

Based on information received and interviews conducted the allegations have been retracted after additional information was discovered by all parties involved. The information provided allowed agencies clarification as it related to the allegations above. This does not mean that the allegations are unfounded, it implies that based on this investigation the allegations are unsubstantiated.

A finding of UNSUBSTANTIATED means that although the violations may have occurred as reported the preponderance of evidence standard was not met.

An exit interview was conducted and a copy of this report with appeal rights given.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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