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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004970
Report Date: 11/04/2021
Date Signed: 11/04/2021 03:43:10 PM

Document Has Been Signed on 11/04/2021 03:43 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 - 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: 5DATE:
11/04/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Stanley Osuka , House ManagerTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facilities annual inspection. LPA met with House Manager Stanley Osuka. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 110 F degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible.

There were no deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility. A copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing..

Exit interview conducted with House Manager Stanley Osuka and copy of report left at facility
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2021
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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