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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002924
Report Date: 08/27/2025
Date Signed: 08/27/2025 03:06:47 PM

Document Has Been Signed on 08/27/2025 03:06 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DELTA SENIOR CARE HOMEFACILITY NUMBER:
397002924
ADMINISTRATOR/
DIRECTOR:		CRIDER,J./ARCAL,A.FACILITY TYPE:
740
ADDRESS:2305 LIDO CIRCLETELEPHONE:
(209) 957-3990
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 6CENSUS: 6DATE:
08/27/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Randy Moranda and Robert ArcalTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct a case management visit. LPA met with Charito De Los Reyes to discuss change of ownership.

The facility has not submitted the required documentation to change ownership. LPA provide the facility with information to complete the process to change ownership.

LPA toured the facility. During the facility visit LPA observed multiple issues with the facility. The medication administration record is not up to date and medications are missing for R1 and R2, Staff (S1) working today is not associated to this facility , S1 is missing first aid CPR certification and R2 need to have an updated physician's report (Lic 602) R2 stated that she is bedridden and she doe not get up to go to the bathroom or have a wheelchair or walker.

Informal meeting will be schedule to address the above concerns.

Deficiencies were cited during today's visit. Civil penalties assessed.

Exit interview conducted.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Albert Johnson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 08/27/2025 03:06 PM - It Cannot Be Edited


Created By: Albert Johnson On 08/27/2025 at 02:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DELTA SENIOR CARE HOME
FACILITY NUMBER: 397002924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/28/2025
Section Cited
CCR
87465(a)(5)

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87465 Incidental Medical and Dental Care Services. (a) A plan for incidental medical and dental care shall be developed by each facility. (5) the licensee shall assist residents with self administered medications as needed.

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Administrator agrees to obtain all missing medications for R1 and R2. Licensee to send in a copy of the centrally stored medication record, indicating missing medications are available. By POC date 8/28/2025.
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this requirement is not met as evidenced by: Based on LPA's observation R1 and R2 are missing medication which poses an immediate potential risk to resident's in care.
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Type A
08/28/2025
Section Cited
CCR87355(e)(1)

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Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption. This requirement is not met as evidenced by:
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Licensee will immediately ensure (S1) is finger print cleared and associated to facility prior to HER reporting to work. Proof of clearance and association shall be submitted to CCL prior to resuming duties.
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interviews and records review, S1 is not associated to this facility
This poses and immediate health and safety risk to residents.
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Administrator shall submit a Statement of Understanding regarding the requirements by POC date via email to CCL.IMMEDIATE CIVIL PENALTY ASSESSED
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Albert Johnson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/27/2025 03:06 PM - It Cannot Be Edited


Created By: Albert Johnson On 08/27/2025 at 02:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DELTA SENIOR CARE HOME
FACILITY NUMBER: 397002924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2025
Section Cited
CCR
87411(c)(1)

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87411-Personnel Requirements - General-Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
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Identified individual shall obtain a current valid first aid certification. This shall be done within 1 day. Facility shall forward a copy to the LPA to clear this deficiency.
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LPA observed no first aid certification For S1. Based on this, facility is in violation of this section.
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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.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Albert Johnson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2025


LIC809 (FAS) - (06/04)
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