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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700885
Report Date: 11/17/2023
Date Signed: 11/21/2023 11:38:14 AM

Document Has Been Signed on 11/21/2023 11:38 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DELTA AT THE PORTSIDEFACILITY NUMBER:
392700885
ADMINISTRATOR:TANYA MONGEFACILITY TYPE:
740
ADDRESS:1950 E SONORA STREETTELEPHONE:
(209) 689-3180
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY: 66CENSUS: 50DATE:
11/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:T. MongeTIME COMPLETED:
12:30 PM
NARRATIVE
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LPA Albert Johnson made an unannounced case management visit and to follow-up on the annual inspection completed on 11/08/2023 and an incident report for an AWOL (resident has not returned).

The facility submitted an incident report dated 11/13/2023 detailing that R1 had signed out and did not return after curfew. R1's physician's report confirmed that she is able to go into the community unassisted. The facility has placed a bed hold with San Mateo County for R1.

LPA was unable to obtain copies of the updated City business license expired 8/31/2023. Additionally the facility was not able to provide a copy of the Surety Bond for this business location. LPA was told that the department should have a copy in the facility file located at CDSS.

Deficiencies are being cited today as a result of this case management visit.

Copy of this report and appeal rights given.

Exit interview conducted.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2023
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 11/21/2023 11:38 AM - It Cannot Be Edited


Created By: Albert Johnson On 11/17/2023 at 11:38 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DELTA AT THE PORTSIDE
FACILITY NUMBER: 392700885

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/24/2023
Section Cited
HSC
1569.60(a)

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ยง1569.60 Surety bond requirement of licensees handing residents funds (a) The director shall require as a condition precedent to the issuance of any license for a residential care facility for the elderly, if the licensee handles or will handle any money of a person within the facility, that the applicant for the license file or have on file with the department a bond issued by a surety company admitted to do business in this state in a sum to be fixed by the department based upon the magnitude of the operations of the applicant, but which sum shall not be less than one thousand dollars ($1,000), running to the State of California and conditioned upon his or her faithful and honest handling of the money of persons within the facility.
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Licensee/ Administrator will get a copy of the surety bond with this facility identifed as the insured and will provide proof of current surety bond along with LIC400 to CCL by 11/24/2023.
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This requirement was not met as evidenced by records reviewed the information provided did not have the facility identifed as the insured.
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Type B
11/24/2023
Section Cited
CCR87405(d)(2)

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(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
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The Licensee/ Adminstrator will get a current copy of the business license from the City of Stockton and provide that information to the department by 11/24/2023.
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The facility is operating with an expired business license expired 8/31/2023. This is a potential safety risk for 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:Lisa Rios
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023


LIC809 (FAS) - (06/04)
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