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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005571
Report Date: 03/02/2022
Date Signed: 03/02/2022 04:39:52 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/02/2022 04:39 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: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: 39DATE:
03/02/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Susan LoTIME COMPLETED:
04:45 PM
NARRATIVE
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On 3/2/22 at 9:45am Licensing Program Analyst (LPA) Kevin Gould arrived at Enclave at the Delta for the purpose of conducting a required 1 year annual inspection. LPA met with staff, Susan Lo and together conducted a tour of the facility.

LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.

LPA measured the water temperature, temperature measured at 125 degrees F in room 10 and 64 degrees in rooms 7, 5 and the shared bathroom which does not meet the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. LPA observed several cameras in and outside the facility. LPA requested to view the monitor and observed Cameras 8, 9 and 10 had unobstructed views to resident bedroom doors and possible when bedroom doors are open, the interior of the bedroom could be visible.

LPA conducted file review and observed that three staff members did not have criminal record clearance prior to working in the facility. Two staff members are still pending clearance and the third staff member shows as invalid. Additionally, several staff did not have their criminal record clearance associated with this facility but still associated to the a sister facility. LPA conducted a review of the medication administration records (MARs) for residents and observed several days in late February that were not documented in the resident's MAR. Every resident MAR reviewed contained dates not signed off by staff. Staff confirmed the missing dates is due to documentation issues and not resident refusal as she would have been notified and residents reassessed.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/02/2022
NARRATIVE
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LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 610E Emergency Disaster Plan, and Current Administrator Certificate.

Per California Code of Regulations, Title 22 the following deficiencies are cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
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Document Has Been Signed on 03/02/2022 04:39 PM - It Cannot Be Edited


Created By: Kevin Gould On 03/02/2022 at 03:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
03/03/2022
Section Cited
CCR
80019(e)(1)

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Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:Obtain a California clearance or a criminal record exemption as required by the Department. This requirement was not met as evidenced by LPA Gould reviewing LIS
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Facility will provide a written plan of correction detailing how the facility will ensure all staff have a criminal record clearance prior to working in, residing or volunteering at the facility.
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 and Guardian criminal record clearance status and observing two staff mebers who are still pending criminal record clearance and one staff with an invalid designation which poses an immediate health, safety and personal rights risk to residents in care.
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Request Denied
Type A
03/03/2022
Section Cited
CCR80075(b)

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Health Related Services: Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by LPA's review of resident's Medication Administration Records (MARs) and observed staff did not record distributing medications to to all residents with consistancy
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Facility will provide retraining for all staff who provide medication assistance to residents to ensure proper documentation of medication administration. Training will be conducted by LPT and facility will submit copies of of all training materials and a proposed training date by the POC duer date.
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which poses an immediate health, safety and persoanl 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.
SUPERVISOR'S NAME:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/02/2022 04:39 PM - It Cannot Be Edited


Created By: Kevin Gould On 03/02/2022 at 04:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
03/02/2022
Section Cited
CCR
80088(e)(1)

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Furniture, Fixtures, Equipment, and Supplies: Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
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LPA observed staff turning down hot water temperature. Facility will monitor hot water temperature and ensure it is withing regulations.
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This requirement was not met as evidenced by LPA testing hot water temperature in room 10 and recorded a temperature of 125 degrees which poses an immediate health, safety and persoanl 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.
SUPERVISOR'S NAME:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022


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