392700885-5-10-2022-27-AS-KHOS-CEGV5M-20220516160810

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700885
Report Date: 05/10/2022
Date Signed: 05/10/2022 03:26:10 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/14/2022 and conducted by Evaluator Bruce Jacobs

COMPLAINT CONTROL NUMBER: 27-AS-20220414153323

FACILITY NAME:	DELTA AT THE PORTSIDE		FACILITY NUMBER:	392700885
ADMINISTRATOR:	ZUBIATE, LEAH LPT		FACILITY TYPE:	740
ADDRESS:	1950 E SONORA STREET		TELEPHONE:	(209) 689-3180
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95205
CAPACITY:	66	CENSUS: 47	DATE:	05/10/2022
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Tanya Monge, Facility Manager		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Facility did not seek timely medical treatment for resident (C-1).

INVESTIGATION FINDINGS:

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LPA Bruce Jacobs conducted an unannounced complaint visit at the facility and met with Facility Manager Tanya Monge for this complaint investigation. LPA provided findings regarding the allegation listed above. The investigation was conducted by LPA Jacobs and consisted of reviews of the facility records and interviews with facility management. Other witnesses were contacted

The complaint allegation listed above was investigated. The facility management and other witnesses were contacted and interviews. The resident has a serious medical condition that requires close monitoring and review of his medical condition. The client had labs done on a regular basis as and those labs were done as required. The facility has also documented that the resident received his medications for his condition without errors or refusals. The facility sent the resident out for evaluation three times when his lab results were critically low and submitted Special Incident Reports for each hospitalization.

Based on LPA’s observations and interviews conducted, the preponderance of evidence standard has not been met, therefore the above allegations are determined to be UNSUBSTANTIATED. Report provided during exit interview.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022

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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