<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004969
Report Date: 09/03/2021
Date Signed: 09/03/2021 02:48:09 PM

Document Has Been Signed on 09/03/2021 02:48 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:
09/03/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:57 PM
MET WITH:Stanley Osuka, House ManagerTIME COMPLETED:
02:40 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
Licensing Program Analyst (LPA) Sarah Hurt arrived to the facility unannounced to conduct a case management visit. LPA met with house manager Stanley Osuagwu and explained the reason for the visit. LPA did a walk through of the facility inside and out. LPA observed several repairs had taken place since the last visit. LPA specifically observed bathroom doors repaired, front glass window repaired, back fence, and broken shutters inside the home had all been repaired. LPA observed all utilities appeared to be working. There was several staff on site. The facility appeared to be in good repair.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies cited during this visit.

An exit interview was conducted with Stanley Osuagwu and a copy of this report was left at the facility.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1