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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004970
Report Date: 09/07/2022
Date Signed: 09/07/2022 02:46:44 PM

Document Has Been Signed on 09/07/2022 02:46 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:
09/07/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Sarah Hurt arrived to the facility unannounced on September 7, 2022 at 02:00 p.m. to conduct a Case management visit. LPA Hurt met with house manager Stanley Osuagwu and explained the reason for the visit.

LPA Hurt did a walk through of the resident bedrooms, bathrooms, kitchen, and living area.. LPA Hurt observed all utilities electricity, gas, and water is working. LPA Hurt observed 7 day non-perishable food supply, and 2 days perishable food supply. LPA Hurt observed at least 30 days supply of medications for clients. Facility staff present stated they are paid twice monthly always on time. LPA Hurt observed two facility caregivers present tending to clients. LPA Hurt observed two facility clients watching a movie in the living area. LPA Hurt observed facility caregiver preparing pork, red potatoes, and garlic bread for the dinner meal. The facility appeared to be clean and 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: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2022
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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