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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005571
Report Date: 05/26/2022
Date Signed: 05/27/2022 11:17:13 AM

Document Has Been Signed on 05/27/2022 11:17 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: 41DATE:
05/26/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Leah ZubiateTIME COMPLETED:
05:00 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
A virtual informal office meeting was conducted today with CCL ASCP Regional Offices including Sacramento South, Sacramento North and Fresno via Microsoft Teams.

Present at the meeting were Regional Managers (RM) Brenda White and Alycia Berryman, Licensing Program Managers See Moua, Liza King, Sergiy Pidgimy and Maribeth Senty, Licensing Program Analysts Maja Jensen, Kerry Hiratsku, Mary Garza and Lady Cabrera, Supervising Auditor Jacqueline Juarez and Auditor Diana Chapman.
Licensee Representative for Everwell Facilities included: Dr. Christopher Zubiate, Madison Fetyko and Tina Perez
This meeting is a result of the solvency audit stemming from a complaint(s) received:

As a result of the audit as well as based on interviews conducted and records reviewed during the investigation of Complaint Number 27-AS-20210119094215, it was determined that the facility did not maintain receipts for cash deposits received for C1. A review of the online Amazon purchases for C1 was conducted. Receipts for purchases in the amounts of $60.30 and $14.28 were verified for Amazon online purchases and were not included on C1’s ledger. In addition, a rent refund check for $503.20 was issued on 6/17/2021 to C1’s mother, for prorated rent due back to C1. This check was not issued in a timely manner as the client was discharged from the facility in February of 2021. Although no money is due back, it was determined that the licensee did not maintain adequate records for the deposits and purchases, including receipts for C1.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached
809D during this visit. Exit interview held, Appeal Rights discussed, Copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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 2
Document Has Been Signed on 05/27/2022 11:17 AM - It Cannot Be Edited


Created By: Maja Jensen On 05/26/2022 at 11:37 AM
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: 05/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2022
Section Cited
CCR
80026(h)(1)

1
2
3
4
5
6
7
Safeguards for Cash Resources, Personal Property, and Valuables of Residents:
(h) Each licensee shall maintain accurate records of accounts of cash resources,
personal property, and valuables entrusted to his/her care, including, but not
limited to the following:
(1) Records of clients' cash resources maintained as a drawing account, which
shall include a current ledger accounting, with columns for income,
disbursements and balance, for each client. Supporting receipts for
purchases shall be filed in chronological order.
(A) Receipts for cash provided to any client from his/her account(s) shall
include the client's full signature or mark, or authorized representative's
full signature or mark, and a statement acknowledging receipt of the
amount and date received, as follows:
"(full signature of client) accepts (dollar amount) (amount written
cursive), this date (date), from (payor).
The following regulation was not met as observed by:
1
2
3
4
5
6
7
The licensee representatives agree to provide LIC 405 forms for residents. The forms will be submitted to CCL by 6/27/2022.
8
9
10
11
12
13
14
Based on observations Licensee did not properly maintain accountancy for client P&I funds during the investigation of Complaint Number 27-AS-20210119094215. The facility did not maintain receipts for cash deposits received for C1. Review of the online Amazon purchases for C1 and verified the receipts for the $385.44 purchases that were identified on the LIC 405. Two additional receipts for $60.30 and $14.28 were provided for Amazon online purchases that were not included on C1’s ledger. A rent refund check for $503.20 was issued on 6/17/2021 to C1’s mother, for prorated rent due back to C1. This check was not issued in a timely manner as the client was discharged from the facility in February of 2021. Although no money is due back, it was determined that the licensee did not maintain adequate records for the deposits and purchases, including receipts for C1. This poses a potential risk to resident's personal rights.
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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2