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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004970
Report Date: 01/19/2025
Date Signed: 01/27/2025 08:38:15 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/27/2025 08:38 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 - MERCER HOME CAREFACILITY NUMBER:
507004970
ADMINISTRATOR/
DIRECTOR:		OSUKA, FESTUS JFACILITY TYPE:
735
ADDRESS:4124 MERCER DRIVETELEPHONE:
(209) 846-9871
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6CENSUS: 3DATE:
01/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Desmond OnahTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived at this facility unannounced to conduct an annual inspection visit. LPA met with facility representative Staff and explained the purpose of the visit. The facility is licensed for 6 residents. 4 ambulatory and 2 non-ambulatory. There are currently 3 residents at this facility.

LPA toured the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms; client bathrooms, laundry area, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the doors and baseboards were not clean. LPA observed sufficient furniture and equipment in client rooms. LPA observed expired food in the refrigerator and the pantry. The hot water temperature was measured at 109*F which was within the required range of 105-120*F.

LPA observed the centrally stored medications area to be locked and inaccessible to client. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair.
LPA reviewed (3) client files and (2) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

Deficiencies were observed and cited on the LIC 809-D pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code. Advisories given for staff file and following the weekly menu.

An exit interview was conducted, a copy of this report, LIC 809-D and appeal rights were provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2025
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 01/27/2025 08:38 AM - It Cannot Be Edited


Created By: Albert Johnson On 01/19/2025 at 11:44 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 - MERCER HOME CARE
FACILITY NUMBER: 507004970

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2025
Section Cited
CCR
80076(a)(1)

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Food Service. Foods shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidenced by
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Administrator shall ensure that all foods are periodically checked for expiration dates. Administrator will also dispose of all expired foods on the premises.
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 LPA observed expired food in the refrigerator and the pantry.
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Please submit a signed LIC 9098 to CCL by POC date indicating that this has been done.

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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:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2025


LIC809 (FAS) - (06/04)
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