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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005571
Report Date: 04/13/2022
Date Signed: 04/13/2022 11:44:14 AM

Document Has Been Signed on 04/13/2022 11:44 AM - 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: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: 40DATE:
04/13/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Susan Lo, Facility SupervisorTIME COMPLETED:
12:00 PM
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On 04/13/2022, Licensing Program Analysts (LPAs)T. White and R. Campbell, conducted an unannounced case management visit regarding an incident report which occurred on 03/03/2022. LPAs met with Supervisor, Susan Lo and explained the purpose of the visit.

LPA White reviewed the incident report submitted to CCLD on 03/12/2022. Based on incident report, Client #1 (C1) walked into the dining room, grabbed the stand-up dust pan, throwing it at Client #2 (C2). The handle of the dustpan struck C2 in the right eye, causing redness and inflammation. Staff #1 (S1) directed all other residents away from the area and contacted 911. C2 was assessed and provided ice pack until EMS arrived.

Based on documentation, C1 was given a 30- day eviction on March 29, 2022 regarding C1's violation to house rules. Based on interview with S1, C1 was transferred to another (sister) Everwell facility in Fresno due to additional behavioral support staff being provided. C1's conservator is currently looking for placement. LPA informed S1 to contact CCLD once C1 has been placed at new facility.

No deficiencies cited during visit.

Exit interview conducted with Supervisor and a copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2022
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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