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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002949
Report Date: 01/22/2025
Date Signed: 01/22/2025 02:56:57 PM

Document Has Been Signed on 01/22/2025 02:56 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 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: 53DATE:
01/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Leonard Willis IITIME VISIT/
INSPECTION COMPLETED:
03:05 PM
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LPAs Kerry Hiratsuka and Cassandra Mikkelson 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.

During today's visit, the following was observed by LPAs: one (1) of the two (2) shower rooms has floor drain that is not draining properly. Facility is working on repairing drain this week.

LPAs reviewed four (4) client files and staff training.

The following shall be updated and submitted to Community Care Licensing by January 30, 2025: facility staff schedule and LIC 308 Designation of Administrative Responsibility.
As a result of today's visit, no deficiencies were cited. Exit interview conducted with Administrator. Copy of this report was left at facility.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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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