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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004970
Report Date: 04/04/2022
Date Signed: 04/05/2022 11:45:51 AM

Document Has Been Signed on 04/05/2022 11:45 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:DELTA STAR - MERCER HOME CAREFACILITY NUMBER:
507004970
ADMINISTRATOR:OSUKA, FESTUS JFACILITY TYPE:
735
ADDRESS:4124 MERCER DRIVETELEPHONE:
(209) 846-9871
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6CENSUS: 6DATE:
04/04/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Facility Staff, Nicetas AbellaTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit to the facility on April 4, 2022 at 10:30 a.m. to conduct a Case Management - Health Checks visit. LPA met facility staff Nicetas Abella and explained the purpose for today's visit.

LPA received a Valley Mountain Regional Special Incident Report documenting that around 11:00 p.m. on March 12, 2022 staff was doing their rounds when staff noticed that Client 1 was not in his bed, right away the whole house was checked and immediately two staff members went out into the community to and drove around to find him. After a couple of hours driving around, staff called Modesto police to help, Officer Campos responded and all information was given to help find Client 1. The following day March 13th at 10 a.m., the facility received a call from Modesto Police that Client 1 was found at McHenry and Briggsmore with 2 CD's in his hand, police said they do not know where he took the CD's from. Client 1 was doing ok but sleepy and tired.
Client 1's IPP documents that he is not able to leave the facility unassisted. Client 1's IPP documents Client 1 will elope from the facility when he has money, and wants to spend his money right away on CD's.

LPA received a phone call on April 2, 2022 from facility staff 1 informing LPA that client 1 was assaulted by Client 2. Client 2 is currently in police custody charged with the Assault of Client 1.

LPA collected physician reports, and IPP's for Client 1 and Client 2.

The following deficiencies are being cited per Title 22 Division 6. An exit interview was conducted with facility staff Nicetas Abella and a copy of this report along with appeal rights was left at the facility.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2022
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 2
Document Has Been Signed on 04/05/2022 11:45 AM - It Cannot Be Edited


Created By: Sarah Hurt On 04/04/2022 at 12:17 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 - MERCER HOME CARE
FACILITY NUMBER: 507004970

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/05/2022
Section Cited
CCR
85078(a)(1)

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85078 Responsibility for Providing Care and Supervision (a)(1)The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs. This requirement has not been met as evidenced by:
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Licensee will conduct in service trainings with facility staff on AWOL and send proof to LPA by 04/05/2022 POC date.
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Based on interviews conducted and records reviewed, the facility did not insure client C1 was appropriately supervised, resulting in C1’s AWOL which posed an immediate health, safety, and personal rights risk to the clients in care.
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Type A
04/05/2022
Section Cited
CCR85065(b)

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85065 Personnel Requirements
(b) The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.
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Licensee will train facility staff on closely monitoring of clients. Licensee will put a plan in place to more closely supervise residents such as 15 minute checks instead of the normal 30 minute checks. Licensee will send proof of this to LPA by 04/05/2022.
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The following requirement has not been met as evidenced by: Based on interviews Client 1 was assaulted by Client 2 after Client 2 showed signs of aggressive behavior earlier in the evening which poses an immediate health, safety or personal rights risk to residents in care.
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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: 04/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2022


LIC809 (FAS) - (06/04)
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