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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700885
Report Date: 02/07/2024
Date Signed: 02/14/2024 03:14:59 PM

Document Has Been Signed on 02/14/2024 03:14 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 PORTSIDEFACILITY NUMBER:
392700885
ADMINISTRATOR:TANYA MONGEFACILITY TYPE:
740
ADDRESS:1950 E SONORA STREETTELEPHONE:
(209) 689-3180
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY: 66CENSUS: 52DATE:
02/07/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:T. MongeTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived at facility on 2/07/2024 unannounced to follow-up on information requested by the department on 10/16/2024 and information received by the department. LPA Johnson met with Tanya Monge and explained the purpose of today's visit. Later joined by Laura Li (CAO) Chief Administrative Officer.

The department received information regarding internal instruction to "not attempt any patient lifting as to avoid any potential back injuries."Based on records reviewed and interviews with staff the facility is using protocols to minimize the potential for additional injuries to the residents after a fall.

The facility provides staff with training through on-line services, this happens during their initial hiring and on-going training. These training include procedures for assessing residents after a fall witnessed or not witnessed. The facility is following the personnel requirements for training under the Title 22 regulations as it relates to 87411 personnel requirements for a Residential Care facility for the Elderly. No deficiencies cited.

As for the follow-up on requested information for S1. The information was requested for on 10/16/2023, the information was never given. The facility sent an email to the department requesting clarification as to the reasoning for the request of information for a staff.

The request is based on inspection authority and will assist in the findings for the allegations listed in the complaint report.

Continued
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 02/14/2024 03:14 PM - It Cannot Be Edited


Created By: Albert Johnson On 02/07/2024 at 12:44 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DELTA AT THE PORTSIDE
FACILITY NUMBER: 392700885

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
02/08/2024
Section Cited
CCR
87755(c)

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87755 Inspection Authority of the Licensing Agency(c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b).
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The facility will amend there program design to include the use of electronic files for staff and residents if this is the method to be used by the facility for evaluations, inspection or other business related to the licensed facility.
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This requirement was not met as evidenced by the lack of records available for inspection after email sent to support the requested information from the LPA's visit on 10/16/2023. LPM Richardson on 10/18/2023 sent an email response to CAO Li confirming that the requested information is relevant to the outcome of this investigation of the allegations.
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Please provide a date when the information to be revised will be updated by 2/8/2024.
Request Denied
Type B
02/21/2024
Section Cited
CCR87411(f)

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(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying.
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The facility will amend there program design to include the use of electronic files for staff and residents if this is the method to be used by the facility for evaluations, inspection or other business related to the licensed facility.
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This requirement was not met as evidenced by lack of records available for inspection on 10/16/2023 and again on this date including the reason for termination or the letter of resignation.
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Additional please provide the requested information for S1 by 2/8/2024
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: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024


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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: 02/07/2024
NARRATIVE
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The department is requesting S1 and S2's file including any corrective actions or coaching. The facility did not have the records available for review as required by 87412 personnel records. During the request for information for S1, information was shared with the department that S1 resigned. After talking with the CAO at approximately 12:50pm, the facility attempted to provide the department with a electronic file for S1, However the electronic file was missing information including why the staff resigned or was terminated.

Deficiencies cited.

An exit interview was conducted and a copy of this report with appeal rights given.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024
LIC809 (FAS) - (06/04)
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