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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002924
Report Date: 10/06/2021
Date Signed: 10/06/2021 09:15:42 AM

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 HOMEFACILITY NUMBER:
397002924
ADMINISTRATOR:CRIDER,J./ARCAL,A.FACILITY TYPE:
740
ADDRESS:2305 LIDO CIRCLETELEPHONE:
(209) 957-3990
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:6CENSUS: 6DATE:
10/06/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Robert ArcalTIME COMPLETED:
09:25 AM
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On 10/6/2021 at 8:45am, Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a case management visit to clear POC's cited on 9/1/2021 during Required- 1 Year annual inspection. LPA met with Administrator and was allowed entry into the facility, today's census is 6 of which 1 resident is receiving hospice.

LPA observed POC for deficiency cited under Title 22 87303(a) has been completed 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 have been repaired or replaced.

LPA observed POC for deficiency cited under Title 22 87705(c)(5) has been completed in that in that R1's medical assessment was completed on 9/21/2021. The licensee has submitted a declaration to to maintain compliance with this regulation at all times to LPA during today's visit.

POC letter generated and provided during today's visit.

Per the California Code of Regulations, Title 22, no deficiencies observed or cited. Exit interview held and a copy of report provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
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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