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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002924
Report Date: 01/20/2023
Date Signed: 01/20/2023 06:38:26 PM


Document Has Been Signed on 01/20/2023 06:38 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
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: 4DATE:
01/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
05:25 PM
MET WITH:Robert ArcalTIME COMPLETED:
06:45 PM
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On 1/20/23 at approximately 5pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual. LPA Jensen met with care provider Robert Arcal and explained the purpose of today's visit.

The facility is a single story structure with 4 bedrooms. 2 room are double occupancy and 2 rooms are single occupancy. At present, none of the residents have a room mate. There are no COVID positive staff or residents. Upon entering there is a table set up in the front hall with a sign in log, thermometer for temperature screening and sanitizer. There are also COVID mitigation signs posted throughout. The facility maintains 2 first aid kits that are complete with scissors, thermometer, tweezers, a manual and various wound dressings. The carbon monoxide detector and smoke detectors were tested and found to be in good working order. The fire extinguishers were last serviced in August of 2022 and are in compliance. All staff was observed to have criminal record clearance and was associated to the facility.

The facility maintains an adequate supply of linen. Night lights were observed in the hallway. The bathrooms were observed to have grab bars at the shower and and at the toilet. The COVID Inspection tool was used and the facility is in compliance with COVID mitigation.

The grounds were observed to be clear of debris. There was some minor fence damage noted that occurred as a result of the recent 22/23 winter storm that the Licensee is actively working to repair.

LPA Requested a copy of the current liability insurance and an updated LIC 500.

No deficiencies were cited as a result of this visit. An exit interview was conducted and a copy of this report and appeal rights were given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
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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