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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002949
Report Date: 03/22/2024
Date Signed: 03/22/2024 10:12:46 AM

Document Has Been Signed on 03/22/2024 10:12 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DELTA AT HOLLY OAKSFACILITY NUMBER:
515002949
ADMINISTRATOR:MELANIE BYRDFACILITY TYPE:
735
ADDRESS:1880 LIVE OAK BLVDTELEPHONE:
(530) 618-5615
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY: 70CENSUS: DATE:
03/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Leonard WillisTIME COMPLETED:
10:20 AM
NARRATIVE
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LPA Hiratsuka conducted this visit to issue a deficiency because this facility changed administrators without notifying Community Care Licensing Division (CCLD) within 30 days of the change as required per Title 22 Regulations.

On July 20, 2024, LPA received a phone call from Melanie Byrd, who informed LPA that Ms. Byrd was resigning as administrator effective July 31, 2024. On September 20, 2024, LPA conducted a visit to follow-up on incident reports and met with Leonard Willis, who stated he is the new administrator. Mr. Willis' administrator certificate was still pending renewal at the time. The licensee did not inform CCLD there was a change of administrator between July 31, 2024 and September 20, 2024. On January 25, 2024, LPA conducted an annual visit and observed Mr. Willis' new administrator's certificate. LPA wrote down on the report that by February 16, 2024, the licensee shall submit paperwork appointing a new administrator as required by Per Title 22 Regulations 85061(b) The licensee shall notify the licensing agency, in writing, within 30 days of a change of administrator. The licensee shall also submit the name, and residence and mailing address of the new administrator, date he/she assumed his/her position, description of his/her background and qualifications, including documentation of required education and certification. A photocopy of the documentation shall be permitted.


As of today, LPA has not received the paperwork appointing who the administrator is and is issuing a deficiency as a result.


Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code. Failure to correct shall result in civil penalties. appeal rights left
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
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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Document Has Been Signed on 03/22/2024 10:12 AM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 03/22/2024 at 09:40 AM
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 AT HOLLY OAKS
FACILITY NUMBER: 515002949

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2024
Section Cited
CCR
85061(b)

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Reporting Requirements. The licensee shall notify the licensing agency, in writing, within 30 days of a change of administrator. Based on record review, the licensee did not comply with the section cited above because Community Care Licensing Division has not received the information
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By 03/29/2024, the licensee shall submit the paperwork required to appoint who the current administrator is. The licensee shall also submit in writing how they shall ensure they shall report such changes as required by title 22 regulations.
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appointing the new administrator as of today. This poses a potential health and safety risk to clients in care.
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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:Troy Ordonez
LICENSING EVALUATOR NAME:Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


LIC809 (FAS) - (06/04)
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