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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004968
Report Date: 01/17/2023
Date Signed: 01/17/2023 03:17:52 PM

Document Has Been Signed on 01/17/2023 03:17 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: 6DATE:
01/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:House Manager Nicetas Abella TIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPA) Jason Lund arrived unannounced to conduct an annual/required inspection. LPA met with House Manager Nicetas Abella and explained the reason for the visit. Census 6

LPA Lund and House Manager Nicetas Abella toured/inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications.

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. All facility staff present is fingerprint cleared.

There were no deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

Exit interview conducted with House Manager Nicetas Abella and a copy of report left at facility
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
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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