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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002949
Report Date: 08/07/2024
Date Signed: 08/07/2024 02:38:50 PM

Document Has Been Signed on 08/07/2024 02:38 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DELTA AT HOLLY OAKSFACILITY NUMBER:
515002949
ADMINISTRATOR/
DIRECTOR:		LEONARD WILLIS IIFACILITY TYPE:
735
ADDRESS:1880 LIVE OAK BLVDTELEPHONE:
(530) 618-5615
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY: 70CENSUS: DATE:
08/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Leonard WillisTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analysts (LPA) Hiratsuka and Mirlohi conducted this unannounced case management visit. LPAs met with Administrator Leonard Willis.

During the visit conducted at the facility on July 10, 2024, LPA Hiratsuka spoke to S1 (LIC 811 Confidential Names) on the phone. S1 provided information indicating involvement in the day-to-day operations of the facility, including access to resident personal information and oversight of the administrator and staff. Based on a review of the California Department of Social Services (CDSS) Guardian Background Check System, Guardian shows that S1 is not associated with this facility. According to California Health and Safety Code, S1’s level of involvement requires an association with the facility. Citation is being issued today for the failure to associate S1 with the facility.

Per California Health and Safety Code §1522(b)(1)(A) regarding fingerprints and criminal records: (b) (1) This section applies to criminal record clearances and exemptions for the following persons: Adults responsible for administration or direct supervision of staff.


Failure to correct shall result in civil penalties being assessed. Appeal Rights provided.


LPA was informed by Administrator that he was not given permission to sign the report by his management team.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
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 08/07/2024 02:38 PM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 08/07/2024 at 01:48 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 AT HOLLY OAKS
FACILITY NUMBER: 515002949

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
09/07/2024
Section Cited
HSC
1522(b)(1)(A)

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Fingerprints and criminal records; exemptions; criminal record clearances: (b) (1) In addition to the applicant, this section is applicable to criminal record clearances and exemptions for the following persons: Adults responsible for administration or direct supervision of staff.
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By 09/07/2024, the licensee shall ensure all staff who supervise other staff shall have criminal record clearance and be associated to the facility. Licensee shall submit in writing how he shall ensure this occurs.
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Based on record review, the licensee did not comply with the section cited above because S1 is not cleared and associated to this facility and supervises staff. This poses a potential health and safety risk to clients in care.
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LPA Hiratsuka was informed by Administrator that he was not given permission to sign the report by his management team.

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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: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
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