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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004969
Report Date: 01/17/2024
Date Signed: 01/17/2024 04:11:27 PM

Document Has Been Signed on 01/17/2024 04:11 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 CAREFACILITY NUMBER:
507004969
ADMINISTRATOR:OSUKA, ADA P.FACILITY TYPE:
735
ADDRESS:2113 QUEBEC COURTTELEPHONE:
(209) 572-3711
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6CENSUS: 6DATE:
01/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Niceta AbellasTIME COMPLETED:
04:20 PM
NARRATIVE
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On 1/17/24 at approximately 1:30pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual inspection. LPA Jensen met with House Manager/Administrator Niceta Abella and explained the purpose of today's visit.

LPA Jensen toured the facility grounds. All paths were clear of obstruction. There are no bodies of water on the property. All window screens were observed to be in good repair. LPA Jensen observed weeds growing in the rain gutters.

LPA Jensen reviewed the Emergency Disaster Plan and determined it to be in compliance. The facility maintains a first aid kit that is complete. The carbon monoxide detector was tested and determined to be in good working order. The fire extinguisher was last serviced in May of 2023 and is in compliance. Medications, cleaning supplies and sharp objects are locked and inaccessible to clients to care. All required postings were observed to be available and prominently displayed. The temperature in the facility was 70 degrees Fahrenheit which falls between the required range of 68-85 degrees. The water temperature in a common bathroom was measured at 109 degrees Fahrenheit which falls within the required range of 105-120 degrees.

LPA Jensen inspected the kitchen and observed in excess of a 2 day supply of perishable food and a 7 day supply of non-perishable food. There was no expired food found. The kitchen has a double oven of which the bottom oven is missing a handle.

LPA Jensen inspected the bedrooms and observed that each bedroom lacked lamps, chairs and night stands but did have adequate storage space with dressers and closets. The existing lighting in the bedrooms was dim relative to the rest of the facility. LPA Jensen observed 3 dressers that were had either missing or non-functional handles.

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
FACILITY NUMBER: 507004969
VISIT DATE: 01/17/2024
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LPA Jensen reviewed 6 staff files and found all documentation to be current and complete. LPA Jensen reviewed 3 client files and found the documentation to be in compliance. LPA Jensen interviewed 1 staff member. No client interviews were conducted as the clients were out of the facility at the time of the inspection.

Technical assistance was provided on changing the Administrator of Record.

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 and appeal rights were 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)
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Document Has Been Signed on 01/17/2024 04:11 PM - It Cannot Be Edited


Created By: Maja Jensen On 01/17/2024 at 03:57 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
FACILITY NUMBER: 507004969

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 weeds growing in the rain gutters and various missing handles, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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The Licensee or facility staff agree to send proof of correction to maja.jensen@dss.ca.gov
Type B
Section Cited
CCR
85088(c)(2)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's observation of bedrooms lacking lamps, night stands and/or chairs, the licensee did not comply with the section cited above in 6 of 6 counts which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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Licensee or facility staff will email photos showing the required furniture has been added or will submit an exception request to maja.jensen@dss.ca.gov.
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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