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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201249
Report Date: 11/07/2025
Date Signed: 11/10/2025 04:16:35 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
09/19/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20250919120610
FACILITY NAME:DELTA SHORES ASSISTED LIVINGFACILITY NUMBER:
079201249
ADMINISTRATOR:JARED PICKARDFACILITY TYPE:
740
ADDRESS:825 E 18TH STREETTELEPHONE:
(925) 706-7944
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:90CENSUS: 80DATE:
11/07/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Beverly Mercurio, Director of Nursing
Sharnell Britton, Care Director		TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Staff mismanaged resident’s medications
Staff did not attend to resident’s call for help
INVESTIGATION FINDINGS:
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On 11/07/25 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with staff (Director of Nursing (DN); Care Director (CD)) to deliver findings of above allegations. LPA explained the purpose of the visit with staff.

During investigation,LPA conducted interviews with staff, toured the facility and obtained the following documents: Personnel record (LIC500), Residents roster, admission agreements, appraisals /needs & services plan, physician's reports, incontinence records, centrally stored medication logs, medication administration 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: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
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-20250919120610
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 LIVING
FACILITY NUMBER: 079201249
VISIT DATE: 11/07/2025
NARRATIVE
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Allegation: Staff mismanaged resident’s medications
Finding: Substantiated
During investigation, LPA interviewed reporting party (RP), facility staff (ADM, S1) and reviewed resident’s (R4) documents. Review of R4’s admission agreement, centrally stored medication logs and medication administration records showed he was first admitted at the facility on 09/11/25 coming from a skilled nursing facility (SNF). On 09/16/25, staff informed R4 that his prescribed medication had run out. Staff (ADM, S1) confirmed with LPA that they failed to follow up with R4’s primary care physician on his prescription refill requirements. Based on interviews and observations which were conducted, the preponderance of evidence standard has been met and the above allegation(s) that staff mismanaged resident’s medications is substantiated.

Allegation: Staff did not attend to resident’s call for help


Finding: Substantiated
During investigation, LPA interviewed reporting party (RP/ Ombudsman (OMB)), facility staff (ADM, S1) and residents (R1, R2). On 09/17/25, RP/Ombudsman witnessed a resident (R1) in Room #207 shouting for help at 3:10PM. RP/OMB informed housekeeping who was cleaning a room on the 2nd floor who called the front desk for help with no staff response. At 3:53PM, RP/OMB informed staff on the 1st floor that R1 needed assistance. RP/OMB stated staff finally arrived around 3:55PM and helped R1. On 09/24/25, ADM confirmed with LPA that residents do not have a call button device available to alert staff for assistance when needed. Based on interviews and observations which were conducted, the preponderance of evidence standard has been met and the above allegation(s) that staff did not attend to resident’s call for help is substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 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
09/19/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20250919120610

FACILITY NAME:DELTA SHORES ASSISTED LIVINGFACILITY NUMBER:
079201249
ADMINISTRATOR:JARED PICKARDFACILITY TYPE:
740
ADDRESS:825 E 18TH STREETTELEPHONE:
(925) 706-7944
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:90CENSUS: 80DATE:
11/07/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Beverly Mercurio, Director of Nursing
Sharnell Britton, Care Director		TIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff left residents in soaked bedding
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/07/25 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with staff (Director of Nursing (DN); Care Director (CD)) to deliver findings of above allegations. LPA explained the purpose of the visit with staff.

During investigation,LPA conducted interviews with staff, toured the facility and obtained the following documents: Personnel record (LIC500), Residents roster, admission agreements, appraisals /needs & services plan, physician's reports, incontinence records, centrally stored medication logs, medication administration records, incident reports.

Continued on next page, LIC 9099-C pg3
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20250919120610
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 LIVING
FACILITY NUMBER: 079201249
VISIT DATE: 11/07/2025
NARRATIVE
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Allegation: Staff left residents in soaked bedding
Finding: Unsubstantiated
During investigation, LPA interviewed reporting party (RP), staff (ED, S1, S2), random residents (R1, R2, R3, R4) and reviewed residents’ documents. Staff (ADM, S1, S2) denied leaving residents in soaked or soiled bedding. S1 stated staff conducts daily care rounds per shift to assist residents with toileting, showering, changing diapers/linens/clothing as needed. Review of residents’ weekly incontinence records dated 08/01/25 until 10/31/25 showed staff provided assistance with residents’ ADLs which included assisting with incontinence care (3X to 4 X per day or as needed), changing wet linens/beddings, toileting, transferring, showering, dressing, grooming, medications, meals and doctors’ appointments. During unannounced visits on 07/03/25 and 08/11/25, LPA observed residents to be clean, well-groomed, odor free and comfortable in their surroundings. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation that staff do not ensure that resident’s incontinence needs are met 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: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20250919120610
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 LIVING
FACILITY NUMBER: 079201249
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/05/2025
Section Cited
CCR
87465(c)(1)
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There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication when the physician should be contacted for a medication reevaluation.
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By POC due date, ADM agreed to complete and submit to CCL in-service staff retraining certifications on residents’ medication management in compliance with Title 22 Section 87465 (c) (1).
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This requirement was not met as evidenced by staff mismanaging resident’s medication which posed a potential health & safety risk to resident in care.
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Type B
12/05/2025
Section Cited
CCR
87468(a)(4)
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To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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By POC due date, ADM agreed to complete and submit to CCL in-service staff retraining certifications on residents’ personal rights in compliance with Title 22 Section 87468 (a) (4).
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This requirement was not met as evidenced by staff did not attend to resident’s call for help which posed a potential health & safety risk to resident 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: 11/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5