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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201249
Report Date: 05/28/2025
Date Signed: 05/28/2025 04:22:27 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/21/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20250521134034
FACILITY NAME:DELTA SHORES ASSISTED LIVIMGFACILITY NUMBER:
079201249
ADMINISTRATOR:DAVID CLAWSONFACILITY TYPE:
740
ADDRESS:825 E 18TH STREETTELEPHONE:
(925) 706-7944
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:90CENSUS: 55DATE:
05/28/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Jared Pickard, Executive DirectorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility is malodorous
Facility is unsanitary
INVESTIGATION FINDINGS:
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On 05/28/25 at 12:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with staff (ED, S1, S2), gathered information and delivered investigation findings to ED. LPA explained the purpose of the visit with staff.

During investigation, the department obtained the following documents from ED – Personnel record, Residents admission agreements, physicians reports, Residents’ roster, Needs & services plans, housekeeping schedules, staff training records, pest control records, incident reports.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20250521134034
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: DELTA SHORES ASSISTED LIVIMG
FACILITY NUMBER: 079201249
VISIT DATE: 05/28/2025
NARRATIVE
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Allegation: Facility is malodorous
Investigation Finding: Substantiated
On 05/28/25 at 1PM, LPA toured the facility with ED and inspected common areas, kitchen, dining room, living room and 5 random bedrooms on the first and second floors (Rms#114A,117A, 119A, 205A, 208A/B). LPA smelled strong bad (feces) odors upon entry into Rms#117A and 119A. The smell of urine was also observed on the first floor common hallway. LPA observed poor ventilation inside the facility with musky odors in common areas, bedrooms and bathrooms. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated.

Allegation: Facility is unsanitary
Investigation Finding: Substantiated
On 05/28/25 at 1PM, LPA toured the facility with ED and inspected common areas, kitchen, dining room, living room and 5 random bedrooms on the first and second floors (Rms#114A,117A, 119A, 205A, 208A/B). LPA observed dirty floors, walls and baseboards in common areas, dining room and living room. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20250521134034
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: DELTA SHORES ASSISTED LIVIMG
FACILITY NUMBER: 079201249
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2025
Section Cited
CCR
87303(a)(1)
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Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
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By POC due date, ED agreed to have common areas, bedrooms, bathrooms, kitchen, living & dining rooms deep cleaned by a professional company and submit a copy of completed cleaning receipt to CCLD.
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This requirement was not met as evidenced by bad odor in bedrooms & bathrooms which posed a potential health & safety risk to residents in care.
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In addition, ED agreed to complete and submit to CCLD in-service house staff retraining on proper cleaning procedures implemented daily at the facility for cleanliness maintenance.
Type B
06/30/2025
Section Cited
CCR
87470(a)(2)(A)
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Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary. These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with blood or body fluids or other potentially infectious material.
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By POC due date, ED agreed to complete and submit to CCLD in-service house staff retraining on proper sanitation practices on a regular basis to ensure facility is safe and sanitary.
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This requirement was not met as evidenced by dirty facility which posed a potential health & safety risk to residents in care.
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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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/21/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20250521134034

FACILITY NAME:DELTA SHORES ASSISTED LIVIMGFACILITY NUMBER:
079201249
ADMINISTRATOR:DAVID CLAWSONFACILITY TYPE:
740
ADDRESS:825 E 18TH STREETTELEPHONE:
(925) 706-7944
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:90CENSUS: 55DATE:
05/28/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Jared Pickard, Executive DirectorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff did not ensure the facility was kept free of pests
Staff are not properly trained
INVESTIGATION FINDINGS:
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On 05/28/25 at 12:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with staff (ED, S1, S2), gathered information and delivered investigation findings to ED. LPA explained the purpose of the visit with staff.

During investigation, the department obtained the following documents from ED – Personnel record, Residents admission agreements, physicians reports, Residents’ roster, Needs & services plans, housekeeping schedules, staff training records, pest control records, incident reports.

Continued on next page, LIC 9099-C pg 1
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20250521134034
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: DELTA SHORES ASSISTED LIVIMG
FACILITY NUMBER: 079201249
VISIT DATE: 05/28/2025
NARRATIVE
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Allegation: Staff did not ensure the facility was kept free of pests
Investigation Finding: Unsubstantiated
On 05/28/25 at 2PM, LPA interviewed staff (S1, S2, S3) who stated that dementia resident (R1) called the police on 05/21/25 complaining about ants and roaches in his room. Staff (S1, S2, S3) stated that police arrived at the facility around 5PM on 05/21/25 and conducted a health check with R1 and inspected his bedroom. Staff stated police did not see any ants or roaches inside R1's bedroom or on his person. S2 confirmed with LPA that she was on duty that day and did not observe any ants or roaches on R1 or inside his bedroom. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not ensure the facility was kept free of pests is unsubstantiated.


Allegation: Staff are not properly trained
Investigation Finding: Unsubstantiated
During investigation, LPA reviewed staff’s training records from 01/01/25 until 05/01/25 which showed staff completed 20 hours of annual training which included reporting requirements, observation of residents and how to address residents’ changes in condition. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that the staff are not properly trained and found it to be unsubstantiated. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are not properly trained is unsubstantiated.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5