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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700892
Report Date: 11/18/2021
Date Signed: 11/23/2021 11:00:42 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/23/2021 11:00 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 FACILITIES IFACILITY NUMBER:
502700892
ADMINISTRATOR:SANDHU, JEEVANJOATFACILITY TYPE:
735
ADDRESS:733 MONIQUE CTTELEPHONE:
(209) 531-6694
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 4CENSUS: 0DATE:
11/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jeevanjoat SandhuTIME COMPLETED:
12:00 PM
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Unannounced annual visit made out to this facility on 11/18/2021 by LPA Charlie Yang to conduct an annual inspection. This LPA was met by the facility designated Administrator, Jeevanjoat Sandhu, who was interviewed.
Current census was 0 residents.
This facility is licensed to accept and retain up to (4) residents at any given time. This facility is vendorized, through Valley Mountain Regional Center, at this time for Level 4I residents.
Tour of this facility was conducted.
Medication cabinet, located in kitchen area , was reviewed. Policies and procedures surrounding medications was discussed with the facility designated Administrator. First aid kit was observed to be present and contained all of the required components at this time.
Kitchen area was toured. Cabinets and drawers were reviewed to make sure that there was a sufficient amount of flatware, dinnerware, and items for resident use.
Food storage units were reviewed to make sure that there was a sufficient supply of 2-day perishable and 7-day nonperishable quantities at all times.
Garage area was toured.
Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
A tour of the resident rooms was conducted. Resident bedroom furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the resident restrooms was conducted. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees.
Fire extinguisher, located in the hallway, was reviewed and observed to have been annually inspected by the local fire extinguisher company.
Linen closet, located in hallway, was reviewed and observed to contain a sufficient amount of linens to meet
the needs of the residents.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2021
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 I
FACILITY NUMBER: 502700892
VISIT DATE: 11/18/2021
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Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.
Exterior grounds of this facility was toured. Perimeter fence and the main gate was observed to be maintained in good repair and in compliance at this time.

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: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
LIC809 (FAS) - (06/04)
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