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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700885
Report Date: 12/05/2022
Date Signed: 12/21/2022 08:50:25 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/21/2022 08:50 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
SACRAMENTO AC/SC, 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: 36DATE:
12/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Heather MobleyTIME COMPLETED:
01:50 PM
NARRATIVE
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Licensing Program Analysts (LPA's) Kesha Lewis and Maja Jensen arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA's were met by Staff member. LPA'S were screened upon entry for COVID precautions. LPA's explained the purpose of the visit to staff. Administrator's Certificate # 6061100740 Expires 111/04/2023

LPA's and Staff inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 66 bed facility with a current census of 36. There is entry door is leading to the waiting area then another door leading to resident bedrooms and office areas, living room, kitchen with a hallway bathrooms. The hallway has COVID precautions in place including social distancing noted. Chemicals and medications noted to be locked to residents in care.

LPA'S observed the Ansul system was serviced 1/19/2022 and is required to be inspected semi-annually service was due 07/19/2022 (photo Taken). LPA'S discovered through records review and interview with staff that medication is prepared and signed for as given before medication pass. For 5 out of 6 residents 5 had missing entries on the MAR. R1-R5 (Photos of MAR'S taken) medication administration records.

Hot water temperature was measured at 106 F degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. LPA's observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: DELTA AT THE PORTSIDE
FACILITY NUMBER: 392700885
VISIT DATE: 12/05/2022
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The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors.

LPA's observed the facility to have hand washing stations, COVID - 19 informational signage, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead individual. The facility is able to designate and dedicated a COVID -19 room/bathroom if needed. Common touch surfaces are cleaned after each use. LPA's observed the facility to have adequate food supply of 7 days non-perishables and 2 days perishables in place. LPA'S observed spoiled food while completing a annual visit. LPA'S took a picture of spoiled food located in the refrigerator, 8 1/2 gallon containers of milk that were passed expiration and moldy. Resident rooms were sanitary and had the required furniture and furnishings.

LPA's observed, fire extinguishers inspected on 06/30/2022 and current, smoke and carbon monoxide detectors, central heating and air in the facility.

Deficiencies were observed and cited from the California Code of Regulations, Title 22.



Exit interview held with staff and copies of reports and appeal rights left at conclusion of visit.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/21/2022 08:50 AM - It Cannot Be Edited


Created By: Kesha Lewis On 12/05/2022 at 12:09 PM
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: 12/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2022
Section Cited
CCR
87202(a)

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All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.. This requirement is not met based on: Observation.
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Administrator will ensure that the fire equipment listed is inspected or a plan is made and sent to CCL by the POC date indicated. Licensee/Administrator shall send picture of the new tags as proof and submit Statement of Compliance.
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The facility failed to maintained in conformity with the regulations adopted by the State Fire Marshal. The "Fixed System" or "Ansul System", this system is scheduled for a annual maintenance and was last serviced on 01/19/22 and is required semi annually. This poses an immediate Health and Safety risk to residents in care.
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Type A
12/06/2022
Section Cited
CCR87465(a)(4)

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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:(4) The licensee shall assist residents with self-administered medications as needed.
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By 12/06/2022 the Administrator shall evaluate the facility's medication distribution practices and submit a revised program plan on medication management to avoid any further medication errors.
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LPA'S discovered through records review and interview with staff that medication is prepared and signed for as given before medication pass. This poses an immediate Health and Safety risk to residents in care.
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Further, additional medication training shall be completed by all staff who handle residents medications by 12/06/22.
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:Kesha Lewis
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/21/2022 08:50 AM - It Cannot Be Edited


Created By: Kesha Lewis On 12/05/2022 at 12:33 PM
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: 12/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
12/15/2022
Section Cited
CCR
87202(a)

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In facilities providing meals to clients, the following shall apply:
(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.
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Facility will do an in-service on food monitoring and food preparation, and keeping kitchens sanitary. Facility will email LPA in-service training documents and sign in sheet by POC Date 12/15/2022. Also suggested is a weekly audit of all food expiration dates.
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This requirement is not met as evidenced by LPA'S observed spoiled food while completing a annual visit. LPA'S took a picture of spoiled food located in the freezer, 8 1/2 gallon containers of milk that were passed expiration and moldy. This poses a potential health and safety risk to residents 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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Kesha Lewis
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2022


LIC809 (FAS) - (06/04)
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