392700885-12-3-2024-27-AS-AJON-DBM89Z-20241203211957

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700885
Report Date: 12/03/2024
Date Signed: 12/03/2024 09:20:55 PM

Document Has Been Signed on 12/03/2024 09:20 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	DELTA AT THE PORTSIDE		FACILITY NUMBER:	392700885
ADMINISTRATOR/ DIRECTOR:	MOMO R DUOA		FACILITY TYPE:	740
ADDRESS:	1950 E SONORA STREET		TELEPHONE:	(209) 689-3180
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95205
CAPACITY: 66	TOTAL ENROLLED CHILDREN: 0	CENSUS: 60	DATE:	12/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:51 PM
MET WITH:	Momo D		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On this date 12/3/2024, Licensing Program Analyst (LPA) Albert Johnson and Licensing Program Manager (LPM) Lisa Rios arrived unannounced to conduct an annual inspection. LPA met with Administrator and explained the purpose of the visit. LPA, LPM and Administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. Observed during the tour were sufficient furniture and lighting throughout the facility. Observed during the tour was sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 106 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. During the tour of the kitchen LPA, LPM and Administrator observed an outdated Ansul system. The system required service on 11/14/24. Fire extinguishers and smoke detectors/carbon monoxide detectors are operational. LPA, LPM and Administrator observed centrally stored medications are kept locked and inaccessible to residents. LPA, LPM and Administrator reviewed and compared resident medication vs. resident medication logs. During the medication review it was observed that medication counts are off and PRN medications are not stored as required. LPA, LPM and Administrator reviewed 15 resident and 10 staff files, including criminal record clearances. S1 is not associated.

Lisa Rios	TELEPHONE: (916) 969-9685
Albert Johnson	TELEPHONE: (916) 217-1390
	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/03/2024

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	During the file review for the residents LPA, LPM and Administrator observed outdated services plan for three of fifteen residents. First aid kit was checked and is complete. Citation given pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted. Appeal rights and report given at conclusion of the inspection.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/03/2024 09:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Incidential medical and dental This requirement is not met as evidenced by: Records reviewed during medication survey. missing medication, documentation inaccurate and centrally stored medication log with missing medication documentation and PRN medication not stored as required.
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/04/2024
	Plan of Correction
1 2 3 4	The Licensee will conduct an in-service on medication adminstration and documentation by POC date 12/4/2024

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Lisa Rios	TELEPHONE: (916) 969-9685
Albert Johnson	TELEPHONE: (916) 217-1390
	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 12/03/2024 09:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87203 fire safety This requirement is not met as evidenced by observation. Ansul system needs to be serviced semi-annually.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/04/2024
	Plan of Correction
1 2 3 4	The licensee will submit a plan or repair/service the Ansul system by poc date.

Section Cited

Criminal record clearance This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/04/2024
	Plan of Correction
1 2 3 4	S1 will be associated to this facility by POC date

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Lisa Rios	TELEPHONE: (916) 969-9685
Albert Johnson	TELEPHONE: (916) 217-1390
	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

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