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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700885
Report Date: 05/20/2025
Date Signed: 05/23/2025 08:47:07 AM

Substantiated


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
02/12/2025 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250212152319
FACILITY NAME:DELTA AT THE PORTSIDEFACILITY NUMBER:
392700885
ADMINISTRATOR:MOMO R DUOAFACILITY TYPE:
740
ADDRESS:1950 E SONORA STREETTELEPHONE:
(209) 689-3180
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY:66CENSUS: 49DATE:
05/20/2025
UNANNOUNCEDTIME BEGAN:
09:49 AM
MET WITH:Aria AlaghenmandTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not provide resident with their weekly allowance.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to deliver findings for the above allegations.

Based on interviews conducted and records reviewed the facility failed to provide C-1 with his money pass on 5/19/2025. C-1 received personal and incidentals(P&I) funds on 5/15/2025 this was the last time C-1 received P&I funds. The facility informed C-1 on 5/19/2025 that he was not able to get his P&I funds because C-1 was late coming to the area where the money was being passed out. The facility does not have a signed policy that addresses consequences of missing money passes or reasons for residents not to get their P&I funds. This is a personal rights violation.

The above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, this deficiency is being cited on the attached 9099-D.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
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 4
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
02/12/2025 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250212152319

FACILITY NAME:DELTA AT THE PORTSIDEFACILITY NUMBER:
392700885
ADMINISTRATOR:MOMO R DUOAFACILITY TYPE:
740
ADDRESS:1950 E SONORA STREETTELEPHONE:
(209) 689-3180
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY:66CENSUS: 49DATE:
05/20/2025
UNANNOUNCEDTIME BEGAN:
09:49 AM
MET WITH:Aria AlaghenmandTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not meet the needs of residents in care
INVESTIGATION FINDINGS:
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 On 5/20/2025, the facility received a finding of unsubstantiated on a complaint for not meeting the residents needs. The information confirmed that C-1 has refused a medication or all medication 22 of 30 days in April of 2025 and 11 of 19 days for May of 2025. This is recorded on the medication administration record and notes on the facilities' recording system for medication management. The facility has addressed this need in the service plan for C-1. The facility did report the refusals in March of 2025 and the doctor made an adjustment, however, C-1 continues to refuse medications and the facility has not consistently followed the intervention plan for C-1. The facility is to continue to report refusals of medication to the physician if the refusal of medications is ongoing. Based on the records the refusal is ongoing and has not been reported for April as per intervention plan created 3/21/2025. Continued

Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20250212152319
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: 05/20/2025
NARRATIVE
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After additional information reviewed and received from the facility. The above allegation is found to be SUBSTANTIATED.

The facility received a citation on 6/3/2025 addressing the medication and service need deficiencies therefore an additional citation is not warranted. The facility will address the deficiencies as part of the in-service for the plan of correction.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20250212152319
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/27/2025
Section Cited
CCR
87468.1(a)(3)
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(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
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Please submit a letter of understanding and a copy of the completed in-service training to include date and signatures of trainer and attendees by POC due date.
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This requirements was not met as evidenced by interviews conducted and records reviewed the facility failed to provide C-1 with his money pass on 5/19/2025.
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Licensee is to ensure that all in-service training are documented and residents' personal rights are upheld at all times.
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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: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4