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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002949
Report Date: 12/17/2024
Date Signed: 12/17/2024 10:58:02 AM

Document Has Been Signed on 12/17/2024 10:58 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/
DIRECTOR:		LEONARD WILLIS IIFACILITY TYPE:
735
ADDRESS:1880 LIVE OAK BLVDTELEPHONE:
(530) 618-5615
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY: 70CENSUS: 51DATE:
12/17/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Leonard WillisTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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On 12/17/2024, Licensing Program Analysts (LPAs) Cassie Yang and Kerry Hiratsuka arrived unannounced at the facility to conduct a health check on residents who were relocated from another facility. LPAs met with Administrator and explained the purpose of the visit.

During today's visit, LPAs conducted interviews with residents in care. Additionally, LPAs obtained a copy of resident roster.

No deficiencies cited.

Exit interview conducted and a copy of report was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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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