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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700885
Report Date: 01/09/2025
Date Signed: 01/09/2025 04:28:34 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
10/02/2024 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20241002120745
FACILITY NAME:DELTA AT THE PORTSIDEFACILITY NUMBER:
392700885
ADMINISTRATOR:TANYA MONGEFACILITY TYPE:
740
ADDRESS:1950 E SONORA STREETTELEPHONE:
(209) 689-3180
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY:66CENSUS: 50DATE:
01/09/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Momo DuoaTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff did not seek medical attention for a resident in care.
Staff called a resident an inappropriate name.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to deliver findings for the above allegations.

During the investigation the department reviewed documents, interviewed staff and residents. Based on this information the department was able to confirm that the facility schedules appointment for residents and provides transportation as well. R1 reported that he has been having chest pains and wants to see a physician. R1 reported that the staff told him that they cannot make an appointment on his behalf. R1 further reported that when he asked the staff if they can take him to the hospital, the staff member said "no I don't want to."
Continued
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
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 2
Control Number 27-AS-20241002120745
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DELTA AT THE PORTSIDE
FACILITY NUMBER: 392700885
VISIT DATE: 01/09/2025
NARRATIVE
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The department was unable to determine the date of the event that the alleged refusal for medical services did occur and R1 was not able to provide a date when this event was alleged to have taken place. The alleged events were to have taken place on the same day which includes staff calling R1 an inappropriate name. The Department reviewed dates and times for scheduled appointments for 2024 including medical, dental and podiatry appointments.


As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2