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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700885
Report Date: 06/03/2025
Date Signed: 06/03/2025 04:00:45 PM

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
02/18/2025 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250218151202
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: 47DATE:
06/03/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Aria AlaghenmandTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff do not keep accurate medication logs.
INVESTIGATION FINDINGS:
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LPA Johnson arrived to deliver findings.

Based on records reviewed and inspections conducted the facility did not keep accurate records for medication. Records reviewed during medication survey confirmed missing medication, documentation inaccurate and centrally stored medication log with missing medication documentation and PRN medication not stored as required. The facility received a citation on 12/3/2024 during the annual survey. 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.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
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
Control Number 27-AS-20250218151202
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: 06/03/2025
NARRATIVE
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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.

The facility stated that they could get the information to show that the doctor was notified and had plans to address the situation, however, the records given show that the facility made the doctor aware of refills on 4/1/2025, 4/02/2025, 4/21/2025 and 4/25/2025 and not that C-1 was refusing medication, Additionally, documentation dated 5/22/2025 and 5/28/2025 addressed the refusal of medication to the doctor after the visit by the department on 5/20/2025.

During the medication review today LPA observed PRN medication is not listed on the authorization letter for C-2 and the medication administration record for C-2 is missing documentation for this PRN medication that was given/popped from the bubbles pack on eleven medication passes.

This allegation is substantiated.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20250218151202
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: 06/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/04/2025
Section Cited
CCR
87465(a)(6)
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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

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The Licensee will conduct an in-service on medication administration, documentation and understanding the service needs of residents by POC date 6/4/2025.
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Based on record review, the licensee did not comply with the section cited above for C-2 which poses an immediate health, safety or personal rights risk to persons in care.
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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: 06/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 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
02/18/2025 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250218151202

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: 47DATE:
06/03/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Aria AlaghenmandTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff yelled at resident.
Staff does not prevent resident from inappropriate behavior.
INVESTIGATION FINDINGS:
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Allegation: Staff yelled at resident. Based on the information provided in the complaint and interviews conducted the facility staff did not yell at a resident. The information provided in the complaint does not identify an actual resident at the facility or a Staff member that was identified as the victim or the perpetrator of the alleged events. LPA reviewed the facility roster of both staff and residents and the names provided in the complaint were not found.

Allegation: Staff does not prevent resident from inappropriate behavior. The information provided in the complaint does not identify an actual resident at the facility or a Staff member that was identified as the victim or the perpetrator of the alleged events. LPA reviewed the facility roster of both staff and residents and the names provided in the complaint were not found.

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

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4