507004968-1-28-2025-27-AS-APAA-DDD2HC-20250128162428

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507004968
Report Date: 01/28/2025
Date Signed: 01/28/2025 04:24:37 PM

Document Has Been Signed on 01/28/2025 04:24 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 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:	01/28/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:00 PM
MET WITH:	Nicetas Abella		TIME VISIT/ INSPECTION COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 1/18/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA was greeted by Staff Member (SM), Dori De Guzman and asked that she callthe Facility Designated Representative (FDR), Necita Abellas that CCL was present. Shortly after, LPA met with FDR Abellas and explained the purpose of the visit. The purpose of this visit was to conduct an annual visit. Current census 6. This facility is licensed to serve 4 nonambulatory residents, 1 ambulatory residents and 1 bedridden. 1 Non-ambulatory resident must be in room 4 with a direct exit. This facility is also vendorized to accept and retain Level 4I residents at this time. A brief interview with FDR Abellas. FDA Festus has a current Administrator Certificate #7002430735 and expires on 12/08/2026. LPA discussed the following items that are required for Administrator change. A review of 3 resident files and 3 staff files were conducted. Both staff and resident files were complete and up to date. A tour of the facility was conducted. Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. A tour of the living area, dining area, and other areas intended for resident use was conducted. Furniture and furnishings were observed to be in good repair. A tour of the kitchen was toured. LPA observed 2 day perishable and 7 day non-perishable food supply to meet the needs of the residents. Knives were observed to be locked and made accessible. A tour of the laundry room was conducted. Laundry supplies such as detergent and toxins were observed to the made inaccessible. A tour of the garage was conducted. Refrigerator was observed to hold additional perishable food supplies. A tour of the backyard was conducted. Perimeter fence and gates were observed to be in good repair. A tour of 2 resident bathrooms were conducted. Hot water temperature was taken to ensure it was within 105-120 degrees. A tour of 4 resident bedrooms were conducted. Each bedroom housed 2 residents. Furniture and furnishings were observed to be in good repair. A linen closet was observed and had sufficient supply.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

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: 01/28/2025

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

The following forms and documents were requested to be updated and submitted into CCL.
-LIC 308
-LIC 400
-LIC 500
-LIC 610

No deficiencies were observed or cited during this annual visit. A copy of this report was given to Facility Designated Administrator.

Exit interview.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

LIC809 (FAS) - (06/04)

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