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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002949
Report Date: 09/20/2023
Date Signed: 09/20/2023 11:49:24 AM

Document Has Been Signed on 09/20/2023 11:49 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: 42DATE:
09/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Leonard Willis and David ShellhamerTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Hiratsuka, conducted this unannounced case management visit in response to two incident reports submitted to Community Care Licensing Division.

On 09/06/2023, and 09/08/2023, one resident pulled the fire alarm pull station. During today's visit the same resident pulled the pull station alarm. LPA inquired what steps the facility is taking to prevent the resident from pulling the alarm.

LPA was informed the resident has been re-evaluated and they have changed the monitoring of the resident.

LPA also discussed the reporting requirement timeline required by the regulations.

No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2023
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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