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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700431
Report Date: 04/26/2023
Date Signed: 05/02/2023 03:43:38 PM

Document Has Been Signed on 05/02/2023 03:43 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 AC/SC, 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:
04/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jeevanjoat SandhuTIME COMPLETED:
01:00 PM
NARRATIVE
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 Unannounced annual visit made out to this facility on 04/26/2023 by Licensing Program Analyst (LPA) Charlie Yang and was met by the facility caregiver, Taswardeep Kaur, who was requested by this LPA to contact the facility designated Administrator, Jeevanjoat Sandhu, to inform him that CCL was present at this time for annual visit.
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 two residents, were out of the facility at their respectable day programs 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 have been annually inspected on 03/29/2023 by the local fire extinguisher company, Jorgensen Company, 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 conducted. 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. Policies and procedures were discussed with the facility designated Administrator in terms of handling, dispensing, and documentation of resident meds.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: DELTA CARE FACILITIES
FACILITY NUMBER: 502700431
VISIT DATE: 04/26/2023
NARRATIVE
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First aid kit was observed to be present and contained all of the required components at this time and observed to be in compliance.
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.
A review of (4) facility residents files was conducted.
A review of (4) facility personnel files was conducted.

The following forms and documents were requested to be updated and submitted into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/02/2023 03:43 PM - It Cannot Be Edited


Created By: Charlie Yang On 04/26/2023 at 12:35 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: DELTA CARE FACILITIES
FACILITY NUMBER: 502700431

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [1] out of [4] personnel files revealed that a facility staff person's first aid had expired which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2023
Plan of Correction
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The facility designated Administrator stated that all facility personnel providing care and supervision to the residents in care will be trained and certified in First Aid at all times. A statement of correction, along with updated and current First Aid cards, will be completed and submitted into CCL by the due date of 05/03/2023.
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [4] out of [4] facility resident files were missing an updated, signed, and completed Admission Agreement (LIC 604) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2023
Plan of Correction
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The facility designated Administrator stated that all facility resident files will contain an updated, signed, and completed Admission Agreement (LIC 604) by the residents and their responsible parties. A statement of correction, along with copies of the updated and current Admission Agreements, will be completed and submitted into CCL by the due date of 05/03/2023.
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:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023


LIC809 (FAS) - (06/04)
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