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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700885
Report Date: 05/26/2022
Date Signed: 05/27/2022 11:36:40 AM

Document Has Been Signed on 05/27/2022 11:36 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:DELTA AT THE PORTSIDEFACILITY NUMBER:
392700885
ADMINISTRATOR:ZUBIATE, LEAH LPTFACILITY TYPE:
740
ADDRESS:1950 E SONORA STREETTELEPHONE:
(209) 689-3180
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY: 66CENSUS: 45DATE:
05/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Leah ZubiateTIME COMPLETED:
05:00 PM
NARRATIVE
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A virtual informal office meeting was conducted today with CCL ASCP Regional Offices including Sacramento South, Sacramento North and Fresno via Microsoft Teams.

Present at the meeting were Regional Managers (RM) Brenda White and Alycia Berryman, Licensing Program Managers See Moua, Liza King, Sergiy Pidgimy and Maribeth Senty, Licensing Program Analysts Maja Jensen, Kerry Hiratsku, Mary Garza and Lady Cabrera, Supervising Auditor Jacqueline Juarez and Auditor Diana Chapman.
Licensee Representative for Everwell Facilities included: Dr. Christopher Zubiate, Madison Fetyko and Tina Perez
This meeting is a result of the solvency audit stemming from a complaint(s) received.

During investigation of Complaint Number 27-AS-20210123161803, interview of the payee provider and Administrator verified that the forms requested by the payee service were not being submitted to the payee, instead documentation that did not include the description and amount spent or withdrawn were submitted. Licensee is not providing adequate documentation to the third-party payee and financial representative for some of the clients.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached
809D during this visit. Exit interview held, Appeal Rights discussed, Copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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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Document Has Been Signed on 05/27/2022 11:36 AM - It Cannot Be Edited


Created By: Maja Jensen On 05/26/2022 at 11:49 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DELTA AT THE PORTSIDE
FACILITY NUMBER: 392700885

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2022
Section Cited
CCR
85072(b)(3)

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Personal Rights: (b) The licensee shall insure that each client is accorded the following personal rights. (3) To have communications to the facility from his/her relatives or authorized representative answered promptly and completely. The following regulation was not met as observed by:

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Licensee agrees that facility will provide LIC 405s or any available receipts requested by the resident’s payee in a timely and appropriate manner. Signed agreement of this will be submitted to the CCL Office by the due date of 6/27/22.
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Based on interviews conducted with the payee provider and Administrator, forms requested by the payee service were not being submitted, instead documentation that did not include the description and amount spent or withdrawn were submitted. This poses a potential risk to resident's rights.
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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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022


LIC809 (FAS) - (06/04)
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