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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004968
Report Date: 01/17/2024
Date Signed: 01/17/2024 12:42:06 PM

Document Has Been Signed on 01/17/2024 12:42 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 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:
01/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Nicetas AbellaTIME COMPLETED:
12:50 PM
NARRATIVE
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On 1/17/24 at approximately 9:45am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual inspection. LPA Jensen met with house manager Nicetas Abella and explained the purpose of today's visit.

LPA Jensen toured the grounds and observed all paths to be clear of obstruction. The facility has a pool that is gated and the gate is locked. The pool is covered and inaccessible. All window screens were observed to be in good repair. There s seating and shaded areas available for outdoor activities.

LPA Jensen inspected the kitchen and observed in excess of a 2 day supply of perishable food and 7 day supply of non-perishable food. There was no expired food observed. Knives were locked and inaccessible to clients in care. Rodent droppings were observed by the side of the kitchen refrigerator.

LPA Jensen observed the bedrooms to contain all required furniture. There is adequate linen on site. Rodent droppings were observed in the master bedroom closet. The water temperature in the master bedroom bathroom was measured at 108 degrees Fahrenheit and is in compliance.

The facility has carbon monoxide detectors that were observed to be in good working order. The fire extinguisher was last serviced in March of 2023 and is in compliance. The facility smoke detectors were observe to be in working order. The facility conducts and logs completed fire drills monthly. The emergency disaster plan was observed to be current. There are at least 3 first aid kits available for client use.

LPA Jensen reviewed 6 of 6 staff files and determined all to be complete and current. LPA Jensen reviewed 5 of 6 client files and found them to be in compliance.

Continued on LIC 809C....
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2024
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 STAR HOME CARE 2
FACILITY NUMBER: 507004968
VISIT DATE: 01/17/2024
NARRATIVE
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LPA Jensen interviewed 1 of 6 facility clients. 5 of 6 clients were out of the facility during the course of this inspection. LPA Jensen conducted a random audit of P&I funds for 2 clients and determined that there was an overage in funds for 1 of clients.

LPA Jensen observed all required postings on the facility walls. The facility posts an activities calendar and maintains a variety of supplies for client engagement. LPA Jensen reviewed the liability insurance and surety bond and determined the policies to be current and have sufficient limits.

Deficiencies are being cited from the California Code of Regulations (CCR), Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/17/2024 12:42 PM - It Cannot Be Edited


Created By: Maja Jensen On 01/17/2024 at 12:26 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 STAR HOME CARE 2
FACILITY NUMBER: 507004968

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and 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:
Deficient Practice Statement
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Based on LPA Jensen's observation of rodent droppings in the kitchen and bedroom, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/24/2024
Plan of Correction
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The Licensee will submit a pest control service receipt/report to maja.jensen@dss.ca.gov.
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:Lisa Rios
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/17/2024 12:42 PM - It Cannot Be Edited


Created By: Maja Jensen On 01/17/2024 at 12:26 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 STAR HOME CARE 2
FACILITY NUMBER: 507004968

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)
Safeguards for Cash Resources, Personal Property and Valuables
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's audit of P&I funds where an overage was observed, the licensee did not comply with the section cited above in 1 of 2 client accounts which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/24/2024
Plan of Correction
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Licensee or facility will conduct an audit of all client P&I funds and send an attestation to maja.jensen@dss.ca.gov that the audit was conducted and the record keeping is accurate.
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:Lisa Rios
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024


LIC809 (FAS) - (06/04)
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