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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700892
Report Date: 10/25/2024
Date Signed: 10/25/2024 01:31:41 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/25/2024 01:31 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/
DIRECTOR:		SANDHU, JEEVANJOATFACILITY TYPE:
735
ADDRESS:733 MONIQUE CTTELEPHONE:
(209) 531-6694
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 4CENSUS: 4DATE:
10/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Jeevanjoat Sandhu, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPAs) Renee Campbell and arrived at the facility to conduct an unannounced annual inspection on 10/25/2024.  LPA Campbell met with Mary Ferrias, Direct Support Provider (DSP) and explained the purpose of the visit. Upon entry, LPA Campbell observed a dining room table and a clear open space with a sofa. A resident was observed coming downstairs for their medicine and to eat breakfast before going to their day program. Two other residents had already left for day program earlier. 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. This facility is a two story building licensed to serve four (4) ambulatory adult residents who are developmentally disabled. There is an administrator certificate under certificate #7015714753 with an expiration date of 4/22/2026.

LPA Campbell observed the facility to be free of odor and clean. LPA Campbell observed bedrooms to be properly furnished with appropriate bedding and lighting and furnishings. There are no bodies of water present. The backyard was free of debris and a pomegranate tree was observed bearing fruit was observed. The fire exit that lead out to the street was clear and unobstructed. A window screen on the first floor was shredded and pulled away from its frame. Of the 4 residents, 2 of the residents medications were audited. LPA reviewed and compared resident medication vs. resident medication logs and found the log to be correctly filled out.was

LPA Campbell observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured in the kitchen and bathroom. The kitchen water temperature measured at 121 degrees and the resident bathroom water temperature measured at 122 degrees. Fire extinguishers were last inspected on March 25, 2024. Smoke and carbon monoxide detectors were tested and are in good repair.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2024
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 I
FACILITY NUMBER: 502700892
VISIT DATE: 10/25/2024
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Facility thermostat was observed at 75 degrees Fahrenheit. LPA Campbell checked medication storage and found medication to be locked away and inaccessible to clients. First aid kit was complete and contained tweezers, scissors and a thermometer. LPA requested client and staff files for review. LPA reviewed 5 resident files and 4 staff files. All staff were associated to the facility. Resident files were complete. Toxins were inaccessible to clients in care. Toxins were stored in the laundry room in locked cabinets.

The following documents will be email to LPA Campbell (Renee.Campbell@dss.ca.gov) by 10/31/2023 by 5:00 PM by end of day:
(1) LIC 308 Designation of Administrative Responsibility
(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate   
(4) LIC 610 Emergency Disaster Plan

Based on today's inspection, per the California Code of Regulations, Title 22, Division 6, Chapter 6, deficiencies were observed or cited and noted on LIC 809D. Note that failure to correct any deficiencies will result in additional civil  penalties.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/25/2024 01:31 PM - It Cannot Be Edited


Created By: Renee Campbell On 10/25/2024 at 01:17 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DELTA CARE FACILITIES I
FACILITY NUMBER: 502700892

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2024
Section Cited
CCR
80087(a)

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80087 Buildings and Grounds
(a) The facility shall be 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:
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Licensee agrees to repair the screen or replace it by the POC date. He will send an image of the window screen repair to renee.campbell@dss.ca.gov
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Based on observation the licensee did not comply with the section cited above by not repairing a torn screen in a window which poses a potential health, safety or personal rights risk to persons 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.
SUPERVISOR'S NAME:Lisa Rios
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2024


LIC809 (FAS) - (06/04)
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