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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700885
Report Date: 10/17/2025
Date Signed: 10/17/2025 12:40:34 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
08/08/2025 and conducted by Evaluator Albert Johnson
COMPLAINT CONTROL NUMBER: 27-AS-20250808091011
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: 44DATE:
10/17/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Madison FetykoTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff did not maintain accurate records for residents
Staff did not provide records to resident's mental health clinician
Staff do not have the required credentials to provide skilled care to residents
INVESTIGATION FINDINGS:
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LPA Johnson and Lund arrived unannounced to deliver findings for the above allegations.

Allegation: Staff did not maintain accurate records for residents, based on records reviewed the facility has records maintained for C-1, however, the records are not accurate as it relates to the required follow-up to notification of the primary care physician. C-1 continues to refuse medication. The facility has attempted to address the refusal, however C-1 refuses to see the doctor. The records are somewhat accurate but lack the required information from the PCP to assist C-1 with alternatives to medication refusal.

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

DATE: 10/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2025
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 2
Control Number 27-AS-20250808091011
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: 10/17/2025
NARRATIVE
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Allegation: Staff did not provide records to resident's mental health clinician. Based on interviews with mental health the facility does provide the case workers with information, however the information is not immediately given. The information is faxed to the case worker and the time frame is different according to the level of information requested.

Allegation: Staff do not have the required credentials to provide skilled care to residents. Based on records reviewed the facility is using a licensed from the California Department of Consumer affairs and NPI registered individual to provide care required by a licensed professional. The department was unable to confirm that this is happening with all required client health needs.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means 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: 10/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2