515002949-1-25-2024-59-AS-KHIA-CZTTR2-20240125135650

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 515002949
Report Date: 01/25/2024
Date Signed: 01/25/2024 01:56:58 PM

Document Has Been Signed on 01/25/2024 01:56 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 OAKS		FACILITY NUMBER:	515002949
ADMINISTRATOR:	MELANIE BYRD		FACILITY TYPE:	735
ADDRESS:	1880 LIVE OAK BLVD		TELEPHONE:	(530) 618-5615
CITY:	YUBA CITY	STATE: CA	ZIP CODE:	95991
CAPACITY: 70		CENSUS: 43	DATE:	01/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Leonard Willis		TIME COMPLETED:	02:00 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	LPA Hiratsuka conducted this unannounced annual visit. LPA toured the facility with Administrator Leonard Willis. This facility has a fire clearance for 70 non-ambulatory residents. This facility has two buildings. The main entrance is in the main building. The main entrance opens to a foyer that has the medication room to the right and the dining and kitchen to the left. The first hallway to the left is going to have two offices, the laundry room, and a break room. The first hallway on the right are two large common rooms, a conference room, and another office. The main building currently has 23 resident rooms that are all going to be shared. The rooms either have a private half-bathroom or some are set up where two rooms share a half-bathroom. The hallway down the middle leads to a second hallway on the left and a second hallway on the right which are all shared resident rooms. There are two common half bathrooms in the middle hallway. There are two common shower rooms. Outside was inspected. There are two enclosed areas and one leads to the second building. The smaller building has 12 resident rooms that may be shared, a small laundry room and a room that has a sink and is going for storage. The rooms either have a private half-bathroom or some are set up where two rooms share a half-bathroom. There is a covered area that is between both buildings.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 OAKS	FACILITY NUMBER: 515002949
	VISIT DATE: 01/25/2024

NARRATIVE

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Ten resident files were reviewed.

Four staff training records were reviewed. The licensee has online training, which is allowed. Per Title 22 Regulations Personnel Records 80066(c) "All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying." LPA had to wait until the corporate office emailed the training logs to the administrator. This took approximately 30-45 minutes. LPA suggested to allow Administrator to have access to the online training records or any forms required by CCLD just in case CCLD requires the facility to provide the personnel records immediately upon request.

The following shall be updated and submitted to Community Care Licensing Division (CCLD) by 02/16/2024:
-Current Administrator. The administrator on record Melanie Byrd, has not worked here since 07/31/2023. 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 has not done that.
-Current mailing address. CCLD received the annual payment notification mailed to the licensee as "undeliverable," after the annual fees were due. The licensee still made the annual fee payment on time.

Several topics were discussed.

No deficiencies cited.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

LIC809 (FAS) - (06/04)

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