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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
507004968
Report Date:
09/16/2024
Date Signed:
09/16/2024 11:33:52 AM
Document Has Been Signed on
09/16/2024 11:33 AM
- 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 2
FACILITY NUMBER:
507004968
ADMINISTRATOR/
DIRECTOR:
OSUKA, FESTUS JOHN
FACILITY TYPE:
735
ADDRESS:
2600 PINOT LANE
TELEPHONE:
(209) 408-8447
CITY:
MODESTO
STATE:
CA
ZIP CODE:
95356
CAPACITY:
6
CENSUS:
6
DATE:
09/16/2024
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:
Dori De Guzaman
TIME VISIT/
INSPECTION COMPLETED:
11:40 AM
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On 9/16/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management for an incident report received for Resident 1 (R1). LPA Jensen was advised R1 resides at a different care home. LPA Jensen spoke to Nessy Abela who advised the address on the incident report was an error. LPA Jensen advised she should fax a corrected report.
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:
09/16/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/16/2024
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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