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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004969
Report Date: 08/09/2021
Date Signed: 08/31/2021 04:28:02 PM

Document Has Been Signed on 08/31/2021 04:28 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 CAREFACILITY NUMBER:
507004969
ADMINISTRATOR:OSUKA, ADA P.FACILITY TYPE:
735
ADDRESS:2113 QUEBEC COURTTELEPHONE:
(209) 572-3711
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6CENSUS: 5DATE:
08/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Nicetas AbellaTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Administrator Nicetas Abella. Administrator's Certification expires 08/17/2021. There are currently 5 residents who reside at this home. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

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. Water temperature was tested at 113.7 F degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible.


The following deficiencies were cited on 809-D per Title 22 Division 6 of the California Code of Regulations.


LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Administrator and copy of report left at facility
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2021
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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Document Has Been Signed on 08/31/2021 04:28 PM - It Cannot Be Edited


Created By: Sarah Hurt On 08/09/2021 at 03:06 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DELTA STAR HOME CARE
FACILITY NUMBER: 507004969

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)



LPA observed the fence boards in decent condition, but the fence itself was falling over and being held up by boards.
Deficient Practice Statement
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. The faciltiy shall be clean safe, and in good repair at all times for the safety and well being of clients, employees, and visitors. Based on LPA observation the fence boards were in decent condition, but the fence was being held up by planks and was falling over. Based on this observation the licensee did not comply with the section cited above in 80087(a) buildings and grounds which poses a potential health, safety or personal rights risk to persons in care
POC Due Date: 09/09/2021
Plan of Correction
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Licensee agrees to repair the fence with cement by POC date. Licensee agreed to send pictures of repaired fence to LPA via email by September 9, 2021
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:Stephenie Doub
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2021


LIC809 (FAS) - (06/04)
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