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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004969
Report Date: 01/28/2025
Date Signed: 01/28/2025 11:56:04 AM

Document Has Been Signed on 01/28/2025 11:56 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 CAREFACILITY NUMBER:
507004969
ADMINISTRATOR/
DIRECTOR:		OSUKA, ADA P.FACILITY TYPE:
735
ADDRESS:2113 QUEBEC COURTTELEPHONE:
(209) 572-3711
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6CENSUS: 5DATE:
01/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Necita Abellas TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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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), Teresita Masangcay and asked that she call the 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 5. This facility is licensed to serve 4 nonambulatory residents and 2 ambulatory residents. 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. FDR Abella has a current Administrator Certificate #6002544735 and expires on 05/22/2025. 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. LPA reviewed the facilities emergency drill log in which it was observed that the facility last conducted their last Fire Drill on 01/06/2025 at 7:00am.
A tour of the facility was conducted. Fire extinguisher was serviced by Jorgenson Co on 08/20/2024 and is in compliance at this time. 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. It was observed that the walls and tiles of the bathroom were peeling away from the walls.
A tour of 3 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.

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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: 01/28/2025
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Bedroom #4 had direct access to the backyard however, the ramp being used had missing pieces of wood on the bottom of the ramp. In addition, the ramp had sections that were observed not have integrity from the wood deteriorating away. LPA conducted a tour of the office and adjacent staff bedroom. Medication was housed in the office which was reviewed and compared with FDR Abella.

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.

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 was provided.
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
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Document Has Been Signed on 01/28/2025 11:56 AM - It Cannot Be Edited


Created By: Arielle Pascua On 01/28/2025 at 11:08 AM
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: 01/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
(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 observation and interview, the licensee did not comply with the section cited above in not ensure that the facility was not in good repair at all times. LPA observed outside ramp from Bedroom #4 had missing wood pieces and did not have intregity due to the wood peeling away. In addition, LPA observed baseboards and other items throughout the facility that needed repair. This poses a potential health, safety, and personal rights risks to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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Administrator stated that the ramp shall be replaced along with other times throughout the facility. Proof of services rendered shall be sent to the LPA by POC date.
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:Lisa Rios
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


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