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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700431
Report Date: 03/19/2024
Date Signed: 03/19/2024 12:21:02 PM

Document Has Been Signed on 03/19/2024 12:21 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: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:
03/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Jeevanjoat Sandhu, AdministratorTIME COMPLETED:
12:45 PM
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On 03/19/24, Licensing Program Analysts (LPA's) Renee Campbell and Avelina Martinez arrived to the facility unannounced to conduct an annual inspection. LPA Campbell met with Jeevanjoat Sandhu, Administrator and explained the purpose of the visit. The administrator's certificate # 6047871735 and will expire on 04/22/2024. The current census is 4 residents with 7 staff.

The facility is a one floor building licensed to service mentally disabled adults ages 18 to 59. Two of the clients may be non-ambulatory. No body of water was found. Upon entry, LPA Campbell observed a resident sitting on the couch in front of the TV with his head bent over while staff was cleaning the other rooms. Another resident entered the facility from outside after going on an outing with another staff member.

LPA Campbell inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. The facility was observed to be free of odor and in good repair. LPA Campbell observed that one resident had a private bathroom. The hot water temperature was measured in the resident bathroom at 116 degrees Fahrenheit which is within the required maximum range of 105 to 125 degrees Fahrenheit. There was a hallway bathroom for the rest of the residents, staff and guests. There were no changes to the building layout since the most recent floor plan.

LPA Campbell and Martinez observed a washer and dryer across from the door to the garage with a freezer and refrigerator as well as shelving for emergency food storage in addition to food observed in the kitchen refrigerator. The temperatures for the freezer and the refrigerator were in compliance.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DELTA CARE FACILITIES
FACILITY NUMBER: 502700431
VISIT DATE: 03/19/2024
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There was enough perishable food within the facility to last 2 days. There was enough non-perishable food to last 7 days as well. In the backyard, LPA Campbell requested to observe the contents of a locked shed. Once the administrator unlocked it, a lawn mower and several empty boxes were observed. The emergency exit was found to have no obstructions.

An electric range, refrigerator with fresh fruits and vegetables were observed by LPA Campbell and the LPA Martinez in the kitchen as well as a monthly menu. Sharps were kept inaccessible from residents in a locked drawer. The smoke / carbon monoxide alarm was tested successfully for the facility. Bedrooms had twin beds, linens, night tables, chairs and closets.

The thermostat was set at 72 degrees Fahrenheit which was between the required minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C). Due to resident behavior, the certification tag had been torn off of the fire extinguisher. However, the administrator had taken a picture of the tag beforehand and the most recent certification date had been 06/19/2023. No deficiencies cited.
The following forms and documents were requested to be updated and submitted into CCL for review by this LPA:
LIC 308 Designation of Facility Responsibility
LIC 400 Affadavit regarding resident cash
LIC 500 Staff Roster
LIC 610 D - Emergency Disaster
LIC 9282 - Infection Control Plan

There were no deficiencies observed or cited during this annual visit at this time.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC809 (FAS) - (06/04)
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