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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700885
Report Date: 11/02/2021
Date Signed: 11/02/2021 01:32:36 PM

Document Has Been Signed on 11/02/2021 01:32 PM - 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: 46DATE:
11/02/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Tanya Monge, Facility ManagerTIME COMPLETED:
11:15 AM
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LPA Bruce Jacobs conducted an unannounced case management visit at the facility and met with Facility Manager Tanya Monge for follow-up on a report of a resident's leaving the facility without permission. The case management visit was conducted by LPA Jacobs and consisted of reviews of the facility records and interviews with facility management.

The facility management and other witnesses were contacted/interviewed by LPA Jacobs. Information obtained from interviews and record reviews document the resident was under supervision and left the facility against the directions of facility staff. The resident's (R-1) Physician's Report (LIC 602) documents that the resident is able to leave the facility unassisted.

Based on all interviews and observations, the resident was able to leave the facility unassisted and this was determined to be a behavior and not inadequate supervision. No deficiencies were identified.

Report provided during exit interview.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2021
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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