507004970-12-8-2023-27-AS-TTRG-CYBSGR-20231208125222

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507004970
Report Date: 12/08/2023
Date Signed: 12/08/2023 12:52:27 PM

Document Has Been Signed on 12/08/2023 12:52 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	DELTA STAR - MERCER HOME CARE		FACILITY NUMBER:	507004970
ADMINISTRATOR:	OSUKA, FESTUS J		FACILITY TYPE:	735
ADDRESS:	4124 MERCER DRIVE		TELEPHONE:	(209) 846-9871
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY: 6		CENSUS: 4	DATE:	12/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Nessy Abella		TIME COMPLETED:	01:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12/8/23, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit. LPA met with facility representative Nessy Abella and explained the purpose of the visit. Administrator holds current certification #6008758735 and expires on 12/7/2023. It was learned that renewal application was submitted last week. The facility is licensed for 6 residents. 4 ambulatory and 2 non-ambulatory. There are currently 4 residents who reside 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 insufficient furniture and equipment in client rooms. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The hot water temperature was measured at 107.2F which was not within the required range of 105-120F. The administrator was advised to reduce the water temperature to be within required range. The temperature inside the facility measured at 75F which was within the required range of 68-85F. 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. Continued on 809-C

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 507004970
	VISIT DATE: 12/08/2023

NARRATIVE

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LPA requested client and staff files for review. LPA reviewed (4) client files and (3) 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. LPA verified staff training for staff file reviews.

The following documents were requested during today's visit:
LIC 308 Designation of Administrative Responsibility, Administrator Certificate, and Proof of Current Liability Insurance, LIC 500 Personnel Report and LIC 610 Emergency Disaster Plan.

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.

An exit interview was conducted, a copy of this report, LIC 809-D and appeal rights were provided. Failure to correct any deficiencies by plan of correction due date(s) may result in civil penalties.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/08/2023 12:52 PM - It Cannot Be Edited

Created By: Tung Truong On 12/08/2023 at 12:19 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
, 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: 12/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85064(b)

Administrator Qualifications and Duties

(b) All adult residential facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Administrator certificate of current administrator has expired on 12/7/23. The administrator did not ensure to renew administrator certificate timely, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/15/2023
	Plan of Correction
1 2 3 4	The Licensee shall appoint a new administrator with active certification and submit documentation to LPA to change facility administrator. POC due by COB 12/15/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Czarrina A Camilon-Lee

LICENSING EVALUATOR NAME:

Tung Truong

LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

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