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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700431
Report Date: 03/28/2024
Date Signed: 03/28/2024 02:28:47 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/28/2024 and conducted by Evaluator Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20240328093213
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:
03/28/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Catherine Torrez, Facility ManagerTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Staff did not ensure that resident was safely transported to their school classroom resulting in resident wandering from their school.
INVESTIGATION FINDINGS:
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On 03/28/24, Licensing Program Analyst Renee Campbell arrived unannounced to deliver findings for the complaint allegation noted above. LPA met with Catherine Torrez Facility Manager and explained the purpose of the visit. Upon entry, LPA Campbell observed a clean and odor free hallway and kitchen. The common area/living room was free of obstructions.

Based on the interviews conducted and documents reviewed, LPA Cambell observed that the allegations have been verified because the licensee/administrator stated that staff (S1) allowed a resident (R1) to enter the building unaccompanied without being handed off to another staff person with the program R1 was attending. R1 was therefore without supervision until the next day when he was found by police.

The department has concluded the investigation and the preponderance of evidence standard has been met and therefore the above allegations are found to be SUBSTANTIATED. California Code of
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20240328093213
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/28/2024
NARRATIVE
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Regulations (Title 22, Division 6, Chapter 8) are cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted via phone and the report was provided..
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20240328093213
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/04/2024
Section Cited
CCR
80078(a)(1)
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NEGLECT & LACK OF SUPERVISION -(a) In addition to Section 80078, the following shall apply: (a)(1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.This requirement was not met as evidenced by:
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Licensee will utilize a transportation log that will require both the facility staff and the destination staff to sign off before the facility staff leaves a resident at a location. A copy of the log will be provided to LPA Cambpell via email at renee.campbell@dss.ca.gov by poc date..
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Based on observation, interview and document reviews R1 was dropped off at a building by staff and allowed to go to class unaccompanied and out of sight. No program staff were present at the time to receive or care for the resident or let them in the classroom. Because R1 cannot be away from the facility unaccompanied, this poses an immediate health, safety, and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3