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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
507004970
Report Date:
09/16/2024
Date Signed:
09/16/2024 12:04:43 PM
Document Has Been Signed on
09/16/2024 12:04 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/
DIRECTOR:
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:
09/16/2024
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:
Stanley Osuagwu
TIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 9/16/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility to conduct a case management related to an incident report received for resident 1 (R1). LPA Jensen met with care staff Stanley Osuagwu and explained the purpose of today's visit.
The Department received an incident report wherein R1 alleged a staff member touched them inappropriately 5 years ago. LPA Jensen conducted an interview with R1. R1 stated that the accusation was lies and that the allegations were made because he was angry about a money situation that has since been sorted out.
LPA Jensen reviewed the P&I ledger and verified that all funds were accounted for.
No deficiencies were observed during the course of this visit. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME
:
Lisa Rios
LICENSING EVALUATOR NAME
:
Maja Jensen
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/16/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/16/2024
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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