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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700885
Report Date: 05/26/2022
Date Signed: 05/27/2022 11:42:20 AM

Substantiated


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
04/06/2022 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20220406101505
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: 45DATE:
05/26/2022
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility is mishandling resident's personal funds.
INVESTIGATION FINDINGS:
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An office meeting was conducted today with CCL ASCP Regional Offices including Sacramento South Sacramento North and Fresno via Microsoft Teams. The purpose of this meeting was to discuss findings from the trust audit conducted by the Department. Present at the meeting were Regional Managers (RM) Brenda White and Alycia Berryman, Licensing Program Managers See Moua, Liza King, Sergiy Pidgimy and Maribeth Senty, Licensing Program Analysts Maja Jensen, Kerry Hiratsku, Mary Garza and Lady Cabrera, Supervising Auditor Jacqueline Juarez and Auditor Diana Chapman.

Licensee Representative for Everwell Facilities included: Dr. Christopher Zubiate, Madison Fetyko and Tina Perez

During the course of the investigation, the department interviewed clients, staff, and the Administrator. Records including P & I Ledgers for the resident were reviewed and copies obtained for the complaint file.

Continued on 9099D....
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20220406101505
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 PORTSIDE
FACILITY NUMBER: 392700885
VISIT DATE: 05/26/2022
NARRATIVE
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The investigation revealed that the majority of the client’s funds are held at the main office in Pismo, CA. Interviews with the administrator and facility managers revealed that the facility is not distributing the P&I funds to the clients as required by regulation. Residents in the facility do not have access to the cash in their accounts. In addition, checks sent to the corporation on the resident’s behalf were returned to the sender without clear explanation and the residents did not get credit for those funds.

The department has concluded the investigation and the preponderance of evidence standard has been met and therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted via phone and the report was emailed return receipt requested.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220406101505
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 PORTSIDE
FACILITY NUMBER: 392700885
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2022
Section Cited
CCR
87468.1(a)(12)
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Personal Rights:
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights.
(12)… and to keep and be allowed to spend their own money.
The following regulation was not met as observed by:
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The licensee agrees that resident’s funds will be redistributed by 6/27/22. The facility will provide 405s for all residents with contact information of the conservators and submit to CCL by 6/27/22.
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Licensee is not distributing P&I to clients and the client’s personal rights to their finances are being violated. The facility is not distributing the P&I funds to the clients per interview with the Administrator and documentation received and reviewed. This poses a potential risk to resident's rights.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3