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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700431
Report Date: 04/21/2022
Date Signed: 04/26/2022 10:11:18 AM

Document Has Been Signed on 04/26/2022 10:11 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:DELTA CARE FACILITIESFACILITY NUMBER:
502700431
ADMINISTRATOR:SANDHU, JEEVANJOATFACILITY TYPE:
735
ADDRESS:1604 COGNAC WAYTELEPHONE:
(209) 531-6694
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 4CENSUS: 4DATE:
04/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jeevanjoat SandhuTIME COMPLETED:
12:30 PM
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 Unannounced annual visit made out to this facility on 04/21/2022 by Licensing Program Analyst (LPA) Charlie Yang and was met by the facility caregiver, April Vasquez, who was requested by this LPA to contact the facility designated Administrator, Jeevanjoat Sandhu, to inform him that CCL was present at this time.
The facility designated Administrator, Jeevanjoat Sandhu, arrived shortly thereafter to this facility. Brief interview was conducted with the facility designated Administrator.
Current census was 4 residents, of which one resident, was out of the facility at their respectable day program at this time.
This facility is also vendorized to accept and retain Level 4I residents through Mountain Valley Regional Center.
Tour of the facility was conducted.
Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Tour of the resident bedrooms was conducted. Bedroom furniture and furnishings were observed to be in good repair and able to meet the needs of the residents at this time.
Tour of the resident restrooms was conducted. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Fire extinguisher, located in dining room, was reviewed to make sure that it had been annually inspected and in compliance at this time.
Laundry room, located adjacent to the garage area, was toured. Laundry detergents, cleaning supplies, and bleach were all observed to be locked and made inaccessible to the residents at this time.
A tour of the garage area was toured. Additional food storage units were observed to be present.
A review of the facility 2-day perishable and 7-day nonperishable food quantities was conducted.
Medication cabinet, located in the dining area, was reviewed.
First aid kit was observed to be present and contained all of the required components at this time and observed to be in compliance.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2022
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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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: DELTA CARE FACILITIES
FACILITY NUMBER: 502700431
VISIT DATE: 04/21/2022
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Linen closet was reviewed and observed to contain all of the necessary blankets, towels, and linens sufficient to meet the needs of the residents at this time.
A tour of the exterior grounds was conducted.
A review of the facility perimeter fence, side gate, and exits was conducted.
The following forms and documents were requested to be updated and submitted into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

There were no deficiencies observed or cited during today's annual visit.

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC809 (FAS) - (06/04)
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