397002924-1-19-2022-27-AS-RWAE-CATTLH-20220119134933

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397002924
Report Date: 01/19/2022
Date Signed: 01/19/2022 01:49:47 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: 5	DATE:	01/19/2022
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	ROBERT ARCAL - ADMINISTRATOR		TIME COMPLETED:	02:00 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	Licensing Program Analyst (LPA) Ruth Wallace arrived unannounced to conduct Required Annual/Random Inspection. LPA contacted Licensee who designated staff one (S1) who arrived at the facility shortly after. LPA 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 5 and 1 hospice residents. 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. S1 stated they are planning a junk removal pick up for items stored in the garage. The hot water was measured at 108.5 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. LPA observed fire extinguishers expire 6/3/2022 and central heating and air in the facility. Seven smoke and carbon monoxide detectors in working order. 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 observed COVID precautions signs posted inside, Observed restrooms stocked with hand soap, hand washing signs posted, touchless covered trash cans, and paper towels in dispenser. LPA observed 30 day supply of PPE stored. Continued on 809-C

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

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: 01/19/2022

NARRATIVE

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Continued from 809

Upon a file review the following items were discussed to be submitted by 02/09/22:
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Liability Insurance
Administrator Certificate
Emergency Disaster Plan LIC610-E
Facility Sketch
Job Descriptions

Per California Code of Regulations (CCRs) - Title 22, Division 6, the following deficiencies are being cited on the attached 809-D 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: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: 01/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(d)(3)

Criminal Record Clearance

(d) All individuals subject to a criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. (3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA review of staff record, the licensee did not comply with the section cited above. S1 did not have a fingerprint clearance for the facility which poses an immediate health, safety or personal rights risk to persons in care. Immediate Civil Penalty of $500.00 will be assessed on today's date.
	POC Due Date: 01/20/2022
	Plan of Correction
1 2 3 4	Licensee agrees to submit a plan of correction by 1/20/2022 stating that all individuals need to be fingerprint cleared before working at the facility. Plan will be submitted via email to LPA Wallace by 1/20/2022 ruth.wallace@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: 01/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(6)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above. Both bathrooms have dry rot, cracked tiles, mold, floors need to be replaced or repaired, tubs/showers need to be repaired or replaced, and bathroom sinks which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/19/2022
	Plan of Correction
1 2 3 4	Licensee agrees to find a contractor to do the repairs or replacement in both bathrooms by Plan of Correction date of 4/19/22. If licensee needs an extension, LPA will be contacted because it is difficult to find contractors at this time. Licensee will submit via email the repair receipts, pictures of repairs or replacements in both bathrooms by 4/19/22. ruth.wallace@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022

LIC809 (FAS) - (06/04)

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