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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005571
Report Date: 06/02/2022
Date Signed: 06/02/2022 10:44:54 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/19/2021 and conducted by Evaluator Treana White
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210119094215
FACILITY NAME:ENCLAVE AT THE DELTAFACILITY NUMBER:
397005571
ADMINISTRATOR:LEAH B ZUBIATEFACILITY TYPE:
735
ADDRESS:4951 EIGHT MILE ROADTELEPHONE:
(209) 210-4863
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY:45CENSUS: 42DATE:
06/02/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Susan Lo, Residential Service SupervisorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is taking away client's personal belongings
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 06/02/2022 at 9:15 AM, Licensing Program Analyst (LPA) T. White arrived unannounced to conclude complaint investigation with the following allegation: Facility is taking away client's personal belongings based on LPA Ashley Boothe’s investigation. LPA White met with Residential Service Supervisor, Susan Lo and explained the purpose of today’s visit. LPA was allowed entry into the facility, current census is 42.

During the course of the investigation, LPA reviewed records and conducted interviews. Resident #1 (R1) experienced instances of personal belongings being held by facility staff without “clear indication why”. R1’s cell phone was held and not released as R1’s responsible party’s request until after 5pm on one instance. R1’s personal packages were withheld after incident of behaviors.

Report continues on 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20210119094215
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ENCLAVE AT THE DELTA
FACILITY NUMBER: 397005571
VISIT DATE: 06/02/2022
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
26
27
28
29
30
31
32
Administrator reported R1 engaged behaviors in violation of house rules and taking his cell phone was part of R1’s behavior plan. R1’s Needs and Services Plan does not document the taking away or withholding items listed as an intervention to R1’s demanding behavior, aggressiveness/agitation, failure to accept consequences, noncompliance/nonadherence, and anxiety. R1’s Targeted Behavior Plan does not document the taking away or withholding item as it states failure to comply “orientation may start again” or “getting a written warning of eviction”.

Based on information obtained the aforementioned allegation is SUBSTANTIATED. A finding that the complaint is substantiated means the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated.

Per California Code of Regulations (CCRs) - Title 22, the following deficiency is being cited on the attached 9099D during this visit. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.

Exit interview conducted with Residential Service Supervisor. A copy of report and Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/19/2021 and conducted by Evaluator Treana White
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210119094215

FACILITY NAME:ENCLAVE AT THE DELTAFACILITY NUMBER:
397005571
ADMINISTRATOR:LEAH B ZUBIATEFACILITY TYPE:
735
ADDRESS:4951 EIGHT MILE ROADTELEPHONE:
(209) 210-4863
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY:45CENSUS: 42DATE:
06/02/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Susan Lo, Residential Service Supervisor TIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Inadequate staffing to ensure safety of clients.
Facility is not administering medications as prescribed.
Staff are calling client inappropriate names.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 06/02/2022 at 9:15 AM, Licensing Program Analyst (LPA) T. White arrived unannounced to conclude complaint investigation based on LPA Ashley Boothe’s investigation with the following allegations: Inadequate staffing to ensure safety of clients, Facility is not administering medications as prescribed, and Staff are calling client inappropriate names. LPA White met with Residential Service Supervisor, Susan Lo and explained the purpose of today’s visit. LPA was allowed entry into the facility, current census is 42.

During the course of the investigation, LPA reviewed records and conducted interviews. Facility staffing schedules were observed consistent and reported by administrator to not have changed over the last seven years. Interviews concluded incidents of staff calling out or being late to shifts but administrator reported back up plan for facility managers to stay late and overtime offered.

Report continues on 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20210119094215
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ENCLAVE AT THE DELTA
FACILITY NUMBER: 397005571
VISIT DATE: 06/02/2022
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
26
27
28
29
30
31
32
Three instances of Staff #1 (S1) working by themselves while other staff were on site in the kitchen and medications room. One staff on site overnight and statements conclude conflicting statements if that is adequate supervision of residents. Resident #1 (R1) Medication Administration Record documented missed medications for refusal, all routine and PRN medications administered per physicians’ order. Medication #1 (M1) alleged to not be administered per physicians’ order not documented on Centrally Stored as prescribed to R1 per R1’s responsible party. R1’s care plan documents demanding behavior “staff will not argue with resident and set clear reminders, still will use a calm voice when speaking to the resident, staff do not argue with the resident”. R1’s care plan documents non compliance behavior “staff do no argue with the resident, instead offer clear reminder the resident already agreed to follow the community rules”. Interviews conclude staff are provided training during on boarding but S1 did not receive additional training upon request to supervisor. One incident S1 reported “she lost it” but could not recall details of calling R1 inappropriate names. Other interview conclude staff may or may not have called R1 inappropriate names during times R1 was engaged in behaviors.

It was determined in the course of the investigation based on the information provided through documentation and interview, the allegations are unsubstantiated. A finding that the allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Per California Code of Regulations (CCRs) - Title 22, no deficiencies are being cited. Exit interview conducted with Residential Service Supervisor and copy of report provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20210119094215
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ENCLAVE AT THE DELTA
FACILITY NUMBER: 397005571
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2022
Section Cited
CCR
85072(b)(6)
1
2
3
4
5
6
7
85072(b)(6): Personal Rights: (b)The licensee shall insure that each client is accorded the following personal rights. (6) To possess and use his/her own personal items

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Supervisor stated the facility staff will review Title 22 personal rights regulations and review personal rights with the residents. Supervisor stated permission will be asked from the resident which will give resident the right to make an independent choice. Supervisor will conduct in-service training and submit proof to CCL by POC date.
8
9
10
11
12
13
14
Based on interview and records review the licensee did not comply with the section cited above in 85072(b)(6) that R1 experienced instances of withholding personal items not documented as part of plan of care which poses a potential health safety and personal right’s risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5