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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005571
Report Date: 12/16/2023
Date Signed: 12/16/2023 01:04:17 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/22/2023 and conducted by Evaluator Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20230822085356
FACILITY NAME:ENCLAVE AT THE DELTAFACILITY NUMBER:
397005571
ADMINISTRATOR:LO, SUSANFACILITY TYPE:
735
ADDRESS:4951 EIGHT MILE ROADTELEPHONE:
(209) 210-4863
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY:45CENSUS: 40DATE:
12/16/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator, Susan LoTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility staff is not providing residents with adequate care and supervision.
INVESTIGATION FINDINGS:
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On 12/16/23, Licensing Program Analyst arrived to the facility unannounced at approximately 11:15 am to deliver findings regarding a complaint investigation. LPA Campbell met with Administrator Susan Lo and stated the purpose of the visit.
Regarding the allegation that facility staff is not providing residents with adequate care and supervision,per the 602, R1 could leave unassisted. However, R2 and S1 stated that R1 left on the same day that they were admitted to the facility and no staff saw them leave. R2 reported that R1 did not speak to anyone and had no altercations on the day that they left. S1 reported that staff did not follow the resident off the facility grounds and R1 never returned to the facility.
The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 6, deficiencies are being cited on the attached 9099D during this visit. If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed. A copy of their rights was provided (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided.


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
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 2
Control Number 27-AS-20230822085356
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ENCLAVE AT THE DELTA
FACILITY NUMBER: 397005571
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
12/22/2023
Section Cited
CCR
80078(a)
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The following is an amendment to the deficiency initially cited on 12/22/23.
80078 Responsibility for Providing Care and Supervision (a)The licensee shall provide care and supervision as nece- ssary to meet the client's needs. This requirement is not met as evidenced by:
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Staff will continue to urge residents to sign in and out and will create an additional plan of action to avoid elopements for new residents to be provided to LPA Renee Campbell at renee.campbell@dss.ca.gov .
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Based on observation & interviews licensee failed to provide care & supervision in order to be aware of the resident’s general whereabouts, lthough resident may travel independently in commuunity.This poses a potential health, safety,personal rights risk to residents in care.
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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: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2023
LIC9099 (FAS) - (06/04)
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