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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700892
Report Date: 11/30/2022
Date Signed: 12/01/2022 11:58:15 AM

Document Has Been Signed on 12/01/2022 11:58 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:
2095316694
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 4CENSUS: 4DATE:
11/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Jeevanjoat SandhuTIME COMPLETED:
03:00 PM
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Unannounced annual visit made out to this facility on 11/30/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility staff (2). This LPA requested that they go ahead and notify the facility designated Administrator, Jeevanjoat Sandhu, who arrived shortly thereafter to this facility while this LPA was conducting this visit. Brief interview was conducted with the facility designated Administrator.
It was learned that this facility is also vendorized through Valley Mountain Regional Center (VMRC) to be able to accept and retain (4) Level 4I residents at any given time.
Current census was (4) residents, of which (2), were out of this facility at their respectable day programs at this time.
Tour of this facility was conducted alongside the facility designated Administrator.
Dining area, living areas, and all other areas designated 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.
A tour of the facility kitchen was conducted.
Food storage was reviewed to make sure that this facility maintained the appropriate 2-day perishable and 7-day nonperishable quantities at all times.
Medication cabinet, located in the kitchen area, was observed to be locked and made inaccessible to the residents at this time. Policies and procedures were discussed with the facility designated Administrator in regards to handling, dispensing, and proper documentation of the resident medications.
First aid kit, located in facility office, was observed to be present and contained all of the required components at this time.
Fire extinguisher, located hanging in the kitchen area, was observed to have been annually purchased on 04/21/2022 by way of the retailer Costco with receipt provided upon request by this LPA and in compliance at this time.
A tour of the facility resident bedrooms was conducted on the second floor. 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 facility resident restrooms was conducted. Hot water temperatures were taken and measured to
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2022
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 I
FACILITY NUMBER: 502700892
VISIT DATE: 11/30/2022
NARRATIVE
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make sure that they were within the allowed range of 105-120 degrees.
Laundry room and area intended for washing, folding, and preparation of the clothes and linens for the residents was toured.
Linens were observed to be present and sufficient to meet the needs of the residents at this time.
Garage area was toured. Additional food storage units and nonperishable food products were observed to be present at this time.
A tour of the facility 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 for review by this LPA:

LIC 308

LIC 400

LIC 500

LIC 610

The following deficiencies were observed and cited during today's annual visit 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 Jeevanjoat Sandhu at this time.

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

DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/01/2022 11:58 AM - It Cannot Be Edited


Created By: Charlie Yang On 11/30/2022 at 02:23 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 I
FACILITY NUMBER: 502700892

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above since particular carpeted areas throughout this facility were soiled and in need of deep cleaning which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2022
Plan of Correction
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Facility designated Administrator stated all carpeted areas will be reviewed and any soiled areas will be deep cleaned and shampooed in order to remove soil and grime and properly clean these areas. A statement of correction, along with pictures of the cleaned carpeted areas, will be completed and submitted into CCL for review by this LPA by the due date of 12/07/2022.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the Licensee did not comply with the section cited above in that several window screens were ripped, torn, or had holes which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2022
Plan of Correction
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Facility designated Administrator stated all window screens will be reviewed and any that were found to have holes, tears, or rips will be repaired/replaced. A statement of correction, along with pictures of the updated window screens, will be completed and submitted into CCL for review by this LPA by the due date of 12/07/2022.
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:Stephenie Doub
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022


LIC809 (FAS) - (06/04)
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