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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700885
Report Date: 10/06/2021
Date Signed: 10/06/2021 11:09:03 AM

Document Has Been Signed on 10/06/2021 11:09 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 AT THE PORTSIDEFACILITY NUMBER:
392700885
ADMINISTRATOR:ZUBIATE, LEAH LPTFACILITY TYPE:
740
ADDRESS:1950 E SONORA STREETTELEPHONE:
(209) 689-3180
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY: 66CENSUS: 28DATE:
10/06/2021
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Tonya MongeTIME COMPLETED:
11:20 AM
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On 10/6/2021 at 9:50am, Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a collateral visit for an open complaint investigation at another facility . Prior to today's visit LPA contacted Administrator regarding facility risk assessment questions. Administrator confirmed no staff or residents have experienced COVID symptoms within the last 10 days. LPA was allowed entry into the facility, current census is 28.

LPA requested records for review and interviewed clients and staff.

Per the California Code of Regulations, Title 22, Division 6, no deficiencies were observed and cited. Exit interview held, copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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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