<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002924
Report Date: 01/25/2024
Date Signed: 01/25/2024 02:57:08 PM


Document Has Been Signed on 01/25/2024 02:57 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 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: 5DATE:
01/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Robert ArcalTIME COMPLETED:
03:05 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 Albert Johnson arrived on 1/25/2024, unannounced to conduct an annual inspection. LPA met with Eva Gahob and explained the purpose of the visit. Later joined by Robert Arcal.

The facility is a RCFE with a current census of 5. The facility has 4 bedrooms and 2 bathrooms. Three bedrooms are being used, one room is empty, but ready for a resident to use. The facility has a formal dining area and a formal living room. LPA conducted the inspection using the CARE tool. LPA and Eva inspected the physical plant including but not limited to the kitchen, bedrooms for residents; two resident bathrooms, laundry area, and backyard area. LPA observed the facility to be free of odor. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 112 degrees Fahrenheit, which is within the required range of 105 to 120 degrees. Fire extinguishers (Dated 9/7/23) and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications (Locked in the kitchen cabinets) and toxin are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 5 resident and 2 staff files, including criminal record clearances. All staff are fingerprint cleared and associated to the facility. First aid kit was checked and is complete. No citations given.

Exit interview conducted. A copy of this report was left with the Staff.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
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 1