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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004968
Report Date: 01/12/2022
Date Signed: 02/01/2022 04:29:08 PM

Document Has Been Signed on 02/01/2022 04:29 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:
01/12/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Facility Staff Dori De GuzmanTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA), Sarah Hurt arrived at this facility today, 01/12/2022 at 1:00pm. LPA met with facility staff The purpose of today's inspection is to clear deficiencies cited on 01/10/2022. LPA observed the water temperature to be 105.1 which is within regulation.

Based upon this inspection, the LPA observed the following:

*Deficiency cited under Title 22 Division 6 Regulation 8088(e)(1) has been cleared. Licensee complied with the terms of the POC by POC due date.

Exit interview was conducted with facility staff Dori De Guzman and a copy of this report was left at the facility.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2022
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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