397002924-9-1-2021-27-AS-ABOE-C6FURZ-20210901154934

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397002924
Report Date: 09/01/2021
Date Signed: 09/01/2021 03:50:03 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	DELTA SENIOR CARE HOME		FACILITY NUMBER:	397002924
ADMINISTRATOR:	CRIDER,J./ARCAL,A.		FACILITY TYPE:	740
ADDRESS:	2305 LIDO CIRCLE		TELEPHONE:	(209) 957-3990
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95207
CAPACITY:	6	CENSUS: 6	DATE:	09/01/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Robert Arcal		TIME COMPLETED:	04:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 9/1/2021 at 1:15pm, Licensing Program Analyst (LPA) arrived unannounced to conduct a Required 1-year Annual Inspection. LPA contacted Licensee who designated staff one (S1) who arrived at the facility shortly after. LPA's was allowed entry into the facility that is licensed to serve a total capacity of 6 residents, hospice waiver for two. Today's census is 6 and 0 hospice residents. Two of two staff observed with criminal record clearance in Licensing Information System. LPA observed Administrator Certificate expires on 12/16/2021. LPA interacted with a random number of residents during this visit. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed kitchen, laundry room, garage, restrooms, bedrooms, and common living areas. LPA observed items stored not in use in the garage, microwave not working and kitchen cabinets with built up grease and food splatter, and floors in second resident room peeling not in good repair. S1 stated they are planning a junk removal pick up for items stored in the garage. The temperature inside the facility was measured at 75F which is within the required range of 68F and 85F, or in areas of extreme heat the maximum shall be 30F less than the outside temperature. The hot water was measured at 110 F which is not less than 105 F and not more than 120*F. LPA observed the centrally stored medications, knives, laundry and garage area to be locked inaccessible to residents. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. Continued on 809 C.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DELTA SENIOR CARE HOME	FACILITY NUMBER: 397002924
	VISIT DATE: 09/01/2021

NARRATIVE

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LPA observed fire extinguisher last inspected 6/3/2021 and central heating and air in the facility. Four of seven smoke and carbon monoxide detectors in working order and three with out working batteries. S1 inspected and replaced all batteries during today's visit. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. LPA did not observed COVID precautions signs posted inside, Observed restrooms stocked with hand soap, hand washing signs posted, touchless covered trash cans, and paper towels not in dispenser. LPA observed less than 30 day supply of PPE stored. LPA to order PPE from the Regional Office during next office day and coordinate pick up or delivery. LPA observed R1 with Dementia last updated assessment in 1/2020.

Upon a file review the following items were discussed to be submitted by 9/17/2021:
Criminal Record Clearances LIS536
Administrative Organization LIC309
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Liability Insurance
Administrator Certificate
Emergency Disaster Plan LIC610E
First aid/CPR certificates

Per California Code of Regulations (CCRs) - Title 22, Division 6, the following deficiencies are being cited on the attached 809D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation and any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report was given.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DELTA SENIOR CARE HOME	FACILITY NUMBER: 397002924
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/01/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in that items stored not in use in the garage, microwave not working order and kitchen cabinets with built up grease and food splatter, and floors in second resident room peeling not in good repair which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/30/2021
	Plan of Correction
1 2 3 4	The licensee agrees to remove, repair or replace all items not clean, safe, sanitary, or in good repair listed above and submit proof of picutres to LPA by POC due date.

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in that R1's last update was 1/2020 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/30/2021
	Plan of Correction
1 2 3 4	The licensee agrees to update residents medical assesments and submit a written declaration of plan to maintain compliance to this regulation at all to LPA by POC due date.

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021

LIC809 (FAS) - (06/04)

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