392700885-4-20-2025-27-AS-LRIS-DG6VHS-20250428162738

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700885
Report Date: 04/18/2025
Date Signed: 04/20/2025 07:24:26 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
01/10/2025 and conducted by Evaluator Albert Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20250110155806

FACILITY NAME:	DELTA AT THE PORTSIDE		FACILITY NUMBER:	392700885
ADMINISTRATOR:	MOMO R DUOA		FACILITY TYPE:	740
ADDRESS:	1950 E SONORA STREET		TELEPHONE:	(209) 689-3180
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95205
CAPACITY:	66	CENSUS: 54	DATE:	04/18/2025
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	F Khan		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff did not prevent resident from severely harming another resident in care
Staff did not provide incident report to resident's authorized representative

INVESTIGATION FINDINGS:

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LPA Johnson conducted a complaint visit to this facility to deliver findings regarding above allegations.

On 11/28/2024, R1 suffered a hip fracture after being pushed to the
ground by another R2. R1 and R2 had a verbal altercation that
R1 took responsibility for. After R1 followed R2 to his bedroom, R2 stated he
pushed R1 with his hand. R1 reported that staff immediately ran to his aid and called
paramedics and law enforcement. Residents were interviewed and reported no concerns with verbal/physical altercations at the facility. Residents also had no concerns regarding R2, who has a history of delusion and paranoia. Both R1 and R2 were said to be very vocal residents.

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025

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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Control Number 27-AS-20250110155806

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: 04/18/2025

NARRATIVE

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Staff who were on duty at the time of the incident did not witness the altercation. Staff reported light concerns regarding staffing; however, no staff believed a lack of staffing, or care, were factors in the incident.

Staff did not witness any physically aggressive behaviors from R1 or R2; however, some staff shared observations of R2 being verbally aggressive to residents and staff. Medical Service Assistant (MSA) Aamenah Ravaid referred to R2 as a “bully, with a short temper” Administrator, Momo Duoa was interviewed and reported that R2 had previous instances of verbal aggression. To mitigate R2’s aggression, Momo stated he has worked closely with R2’s San Joaquin County Behavioral Health team to provide R2 with the necessary support.

Allegation: Staff did not provide incident report to resident's authorized representative

IB inquired about the facility’s alleged refusal to provide the associated incident report to R1’s LPS conservator, Sharon McLaughlin. Sharon was interviewed and stated she reached out to the facility and Administrator, Momo Duoa, multiple times from 12/6/2024 to about 1/8/2025. According to the Unusual Incident Report (UIR), the facility contacted Sharon on 12/3/2024. Administrator Momo Duoa was asked about Sharon’s efforts to obtain the UIR and Momo had no recollection of Sharon’s requests. Sharon also spoke with an EverWell Health Systems staff named Martha (unknown) who was unable to assist her with her request.

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: 04/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025

LIC9099 (FAS) - (06/04)

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