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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700885
Report Date: 03/28/2024
Date Signed: 03/28/2024 12:04:03 PM

Document Has Been Signed on 03/28/2024 12:04 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:
03/28/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:38 AM
MET WITH:T. MongeTIME COMPLETED:
12:15 PM
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On 3/28/24, LPA Johnson arrived unannounced to conduct a plan of correction and case management visit. LPA met with Administrator T. Monge and explained the purpose of the visit.

The following deficiencies, initially cited during a visit on 03/13/2024, have been cleared: Section Cited: 87465(I) Date Due: 03/28/2024.

Plan of Correction:

The facility will provide training to all med-tech on medication records and destruction of medication with documentation by 3/28/2024. The training will be included in the med-techs file. Corrections: Cleared by Visit Clearance Date: 03/28/2024.

The facility confirmed that the in-service have been conducted and the information will be in the med-tech's files for review by the department during visits.

The department received two incident reports with information regarding two visits on two separate occasions to the emergency room for R1 and R2.

R1 was discharged back to the facility with the standard recommendation to follow-up with primary care provider within 1 to 3 days. No medication changes.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
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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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: 03/28/2024
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R2 was discharged back to the facility with a new medication. The new medication has been started and the standard recommendation to follow-up with primary care provider within 1 week has been recommended.

An exit interview was conducted and a copy of this report was provided to the Administrator.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC809 (FAS) - (06/04)
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