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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700892
Report Date: 11/16/2023
Date Signed: 11/16/2023 03:56:06 PM

Document Has Been Signed on 11/16/2023 03:56 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 FACILITIES IFACILITY NUMBER:
502700892
ADMINISTRATOR:SANDHU, JEEVANJOATFACILITY TYPE:
735
ADDRESS:733 MONIQUE CTTELEPHONE:
(209) 531-6694
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 4CENSUS: 4DATE:
11/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Hector Manuel Gomez, Direct Care StaffTIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPA) Renee Campbell arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA Campbell was met by House Manager Catherine Torrez, and later Hector Gomez, Direct Care Provider and explained the purpose of the visit. The Administrator is Jeevanjoat Sandhu (#6047871735) who was not present but gave permission for staff to assist in annual inspection.

LPA Campbell and the House Manager inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 4 bed facility with a current census of 4 residents. Pathways were clear of obstructions. There is also a room for an office with an attached bathroom. In all, there are three bathrooms in the facility. There is an entry door leading through the living room to the kitchen and day room. The office and laundry room are found on the first floor under the stairs. Chemicals were locked in the facility office, away from residents. Kitchen knives were also locked in a cabinet in the kitchen. LPA also conducted the infection control domain tool. File reviews were completed for 2 of 10 staff and 2 of 4 residents. A Fire Drill was last done on 10/14/23 and the fire extinguisher was last serviced on 03/29/2023. The Infection Control Plan was observed and LPA Campbell audited medications for 2 of the 4 residents.

Hot water temperature was measured at 120 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
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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