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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005571
Report Date: 01/19/2024
Date Signed: 01/22/2024 04:56:45 PM

Document Has Been Signed on 01/22/2024 04:56 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:
01/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:42 PM
MET WITH:Susan LoTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced on 1/19/2024 at approximately 2:45pm to conduct a Case Management visit. LPA met with Susan Lo and stated the purpose of the visit which is to obtain additional information regarding a death of a resident.

LPA requested additional information including the police report number for the event with R1, the Corners report number and any documents provided to the facility regarding this matter, also the department is requesting the responding paramedic information(i.e...reports, report number).

LPA was informed that the conservator has the requested information, and the department should contact the Conservator to get the above requested information.

The facility should be able to assist with the request to obtain report numbers from the Officers that responded to the incident as well as the other requested information. The staff on duty would have been provide with report numbers during or at the end of their on scene investigation.

Please provide report numbers as requested to the department via fax or email by the close of business on 1/23/2024.

A copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024
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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