079201249-5-27-2026-15-AS-BFOG-DUYV3D-20260612160435

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201249
Report Date: 05/27/2026
Date Signed: 05/27/2026 12:33:29 PM

Unsubstantiated

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
05/21/2026 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20260521153649

FACILITY NAME:	DELTA SHORES ASSISTED LIVING		FACILITY NUMBER:	079201249
ADMINISTRATOR:	JARED PICKARD		FACILITY TYPE:	740
ADDRESS:	825 E 18TH STREET		TELEPHONE:	(925) 706-7944
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	90	CENSUS: 89	DATE:	05/27/2026
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Beverly Mercurio, Director of Nursing Amanda Stewart, Marketing Director		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility refused to accept resident back to facility after hospital visit

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 05/27/26 at 10:30AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with staff (DN, MD), gathered information and delivered investigation findings to DN. LPA explained the purpose of the visit with staff.

During investigation, the Department obtained the following documents from DN – Personnel record, Resident roster, R1's admission agreement, physicians reports, Needs & services plans, emails regarding R1's unsafe behavior and need for hospitalization, After discharge summary report, incident report.

Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026

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 2

Control Number 15-AS-20260521153649

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: 05/27/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Facility refused to accept resident back to facility after hospital visit
Investigation Finding: Unsubstantiated
On 05/27/26 at 10:30AM, LPA interviewed staff (DN, MD) who stated that dementia resident (R1) was sent to the hospital on 05/16/26 due to unsafe, aggressive behaviors towards staff and other residents as a result of her refusal to take her medications. R1 was admitted at the hospital with a diagnosis of altered mental state. Prior to R1's hospitalization, MD stated that she communicated with the hospital's Program Director (PD) and social worker (RP) via text messages on 05/15/26, alerting them that R1 may be sent to the hospital due to her unsafe behavioral expressions towards staff and other residents. MD stated she visited and assessed R1 on 05/19/26 and 05/26/26, discussed R1's unsafe behaviors with PD and RP and told them that R1 needs to take her medications so that staff can manage her behavioral expressions. R1 stayed at the hospital for 10 days and was safely released back to the facility on 05/26/26. DN stated R1 is currently taking her medications which allows staff to provide her with proper care and supervision. During visit, LPA observed R1 to be calm and comfortable in her surroundings while having lunch with other residents in the common dining area of the facility. 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 facility refused to accept resident back to the facility after hospital visit was found to be unsubstantiated.

No deficiency cited during visit.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 2