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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004968
Report Date: 01/10/2022
Date Signed: 01/12/2022 12:59:08 PM

Document Has Been Signed on 01/12/2022 12:59 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:DELTA STAR HOME CARE 2FACILITY NUMBER:
507004968
ADMINISTRATOR:OSUKA, FESTUS JOHNFACILITY TYPE:
735
ADDRESS:2600 PINOT LANETELEPHONE:
(209) 408-8447
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6CENSUS: 5DATE:
01/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Facility Staff Nicetas AbellaTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with facility staff Nicetas Abella. Continual Administrator's Certification expires 07/31/2023 . There are currently 5 residents who reside at this home. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. LPA observed water temperature to be 123 degrees which is outside of regulations.

The following deficiencies are being cited during today's inspection per California Code of Regulations, Title 22 Division 6, Chapter 6. Exit interview conducted with facility staff Nicetas Abella and copy of this report along with appeal rights left at the facility.

LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/12/2022 12:59 PM - It Cannot Be Edited


Created By: Sarah Hurt On 01/10/2022 at 12:06 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 STAR HOME CARE 2
FACILITY NUMBER: 507004968

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
8088(e)(1)


(e) Faucets used by clients for personal care such as shaving, and grooming deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degreesF(40.5 degreesc) and not more than 120 degrees F (48.8 degreesC)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's testing of water temperature, the licensee did not comply with the section cited above due to the recorded temperature of water being 123 degrees F which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/12/2022
Plan of Correction
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LPA will conduct POC visit to ensure the hot water is within regulation between 105 and 120.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephenie Doub
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2022


LIC809 (FAS) - (06/04)
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