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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700885
Report Date: 12/18/2024
Date Signed: 12/18/2024 12:39:31 PM

Document Has Been Signed on 12/18/2024 12:39 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:		MOMO R DUOAFACILITY TYPE:
740
ADDRESS:1950 E SONORA STREETTELEPHONE:
(209) 689-3180
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY: 66CENSUS: 52DATE:
12/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Momo DuoaTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
NARRATIVE
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LPA Johnson and Lund arrived unannounced and met with the Administrator who assisted LPA with the visit.

The purpose of this visit was to follow up on a request by the department to review the new admits to the facility and plan correction. LPA's toured the facility to follow-up on the verbal advisories given during the annual inspection and continued inspection on 12/3/2024 and 12/6/2024.

The facility presented a work order for a resident bathroom across from room #2 and #3 that was dated 11/22/2024 for a clogged toilet. Today the door was unlocked and accessible to residents. Also observed were buildings and grounds violations including kitchen cleanliness with food behind the stove, food with out expiration dated, and broken blinds in multiple rooms.

LPA conducted records review of resident roster and staff roster and obtained copies.

Citation given as a result of this visit.

Exit interview conducted and appeal rights given.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
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 12/18/2024 12:39 PM - It Cannot Be Edited


Created By: Albert Johnson On 12/18/2024 at 11:39 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: 12/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/18/2024
Section Cited
CCR
87303(a)(1)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
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The facility will complete the work orders for the items presented to the department 12/6/2024.
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This requirement is not met as evidenced by observation and photos taken. The facility presented a work order for a resident bathroom across from room #2 and #3 that was dated 11/22/2024 for a clogged toilet. Today the door was unlocked and accessible to residents. Also observed were buildings and grounds violations including kitchen cleanliness with food behind the stove, food with out expiration dated, and broken blinds in multiple rooms.
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The facility will provide the department with a cleaning schedule for daily, weekly and monthly task.

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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: 12/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2024


LIC809 (FAS) - (06/04)
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