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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004970
Report Date: 03/09/2022
Date Signed: 03/09/2022 11:26:32 AM

Document Has Been Signed on 03/09/2022 11:26 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: 5DATE:
03/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Stanley OsuagwuTIME COMPLETED:
11:30 PM
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Licensing Program Analyst (LPA) Sarah Hurt arrived to the facility unannounced on March 9, 2022 at 9:45 a.m. to conduct a case management visit. LPA met with house manager Stanley Osuagwu and explained the reason for the visit. LPA did a walk through of the facility inside and out. LPA observed all utilities electricity, gas, and water is working. LPA observed plenty of food in the fridge. LPA observed at least 30 days supply of medications. Facility staff present stated they are paid twice monthly on time. There was several staff on site. The facility appeared to be in good repair.

Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 6, no deficiencies cited during this visit.

An exit interview was conducted with Stanley Osuagwu and a copy of this report was left at the facility.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2022
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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