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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700885
Report Date: 10/07/2024
Date Signed: 10/08/2024 12:11:34 PM

Document Has Been Signed on 10/08/2024 12:11 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/
DIRECTOR:		TANYA MONGEFACILITY TYPE:
740
ADDRESS:1950 E SONORA STREETTELEPHONE:
(209) 689-3180
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY: 66CENSUS: 46DATE:
10/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Kelly SternTIME VISIT/
INSPECTION COMPLETED:
01:55 PM
NARRATIVE
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LPA Johnson arrived unannounced to conduct a complaint investigation and case management visit. LPA met with Administrator Kelly Stern and explained the purpose of the visit.

LPA requested a tour of the facility, during the tour of the facility LPA and Administrator observed and photographed unlocked toxin/ cleaning supplies on the cleaning cart. The cart does lock and has a key; however, the locker area was being used to store paper supplies and not the cleaning product. (Citation given)

The facility's buildings and grounds needed attention in two areas: the first area included the vents in the hallways have no filters and are covered with build-up dust (photos taken). Also observed throughout the facility were broken or missing blinds in several rooms including the T.V. Room. (Advisories given)

The facility will not provide the department with copies of the resident face sheets. The facility stated that these are internal documents and only to be viewed and not copied for the department.(Citation given). LPA took photos of the face sheet to assist the investigation of the complaint. LPA was confronted about the photos and was told that the facility will not sign the reports. Because the LPA was observed taking photos of the face sheets. LPA asked Momo Duoa for copies of the facesheet again was told that a copy of the LIC 9020A was be provided. The form provided was not a LIC form but a facility form with similar information for all residents not the two residents that information was requested for R1 and R2.



The citations are included on the attached 809D Page.

An exit interview was conducted and a copy of this report and appeal rights were provided to the Administrator.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2024
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 10/08/2024 12:11 PM - It Cannot Be Edited


Created By: Albert Johnson On 10/07/2024 at 12:12 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: 10/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/08/2024
Section Cited
CCR
87309(a)

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87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
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Licensee will provide training to new employees regarding this regulation cited and will provided the department with the attendees of this in-service by the POC date 10/8/2024
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Based on observation, the licensee did not comply with the section cited above. LPA observed a cleaner unlocked on the cleaning cart unattended observed to be accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
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The department can be notified by email or fax with the required information request in the plan of correction.
Type A
10/08/2024
Section Cited
CCR87755(c)

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(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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The facility will not provide the department with copies of the resident face sheets. The facility stated that these are internal documents and only to be viewed and not copied for the department. The facility offered a Licensing form 9120 in lieu of the face sheet.
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The facility will also provide the department with an in-service for all staff to review the regulation 87755 Inspection Authority of the Licensing Agency. The department can be notified by email or fax with the required information request in the plan of correction.
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: 10/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024


LIC809 (FAS) - (06/04)
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