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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005571
Report Date: 01/03/2024
Date Signed: 01/03/2024 12:02:00 PM

Document Has Been Signed on 01/03/2024 12:02 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 38DATE:
01/03/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Susan Lo, Assistant Administrator and Laura Li, Chief Administrative OfficerTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 1/3/24 at 9a to conduct a Case Management Health and Safety Check on residents in care. LPA met with Susan Lo and stated the purpose of the visit which is to obtain additional information regarding a death of a resident. However, upon arrival LPA was informed the facility has 7 residents with a rash. Being that this is a health and safety case management visit, the purpose is now to obtain information on the death and on the possible outbreak. LPA spoke with Susan Lo, Assistant Administrator and Laura Li, Chief Administrative Officer via conference call during this visit and stated the purpose.

LPA obtained information regarding the circumstances of Resident #1 (R1's) death. LPA also requested the following: Personnel Report (LIC500), Identification and Emergency Information, (LIC 601), Staff work schedule for December 2023, Staff roster with contact information, Resident roster, Any Unusual Incident/Injury reports (LIC624) regarding R1 and/or facility notes, Admission Agreement, Medication Logs, and Administrator Certificate

LPA requested the following regarding the Rashes - Possible Outbreak:
Names, dates and diagnosis of each resident and/or staff, date Public Health Notified with any advice given, statement that Infection Control Plan is being followed.

Laura Li stated that she will fax all information for residents (R2-R8) residents regarding the rashes, as well as R1's facility file information today.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations were cited during this visit. An exit interview was conducted with Susan Lo and Laura Li via Microsoft Teams Meeting and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2024
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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