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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600400
Report Date: 05/05/2023
Date Signed: 05/05/2023 11:34:06 AM


Document Has Been Signed on 05/05/2023 11:34 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:DELL'S RESIDENTIAL HOMEFACILITY NUMBER:
075600400
ADMINISTRATOR:MITCHELL, TRACYFACILITY TYPE:
735
ADDRESS:4444 BELLE DRIVETELEPHONE:
(925) 978-0345
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:4CENSUS: 3DATE:
05/05/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Kate Ndulaka, Direct Support StaffTIME COMPLETED:
11:45 AM
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On 5/5/2023 at 10:20AM, Licensing Program Analysts (LPAs), L. Hall and C. Fowler arrived unannounced to conduct a case management conduct a health and safety check as a result of the department receiving a complaint (15-AS-20230503081459). LPAs met with Kate Ndulaka, Direct Support Staff, and explained the reason for the visit. LPA spoke with Administrator, Tracy Mitchell, via telephone and was given approval for staff to sign documents.

Upon arrival, LPA observed one staff S2 and 3 clients were in common areas. One staff S3 arrived shortly after. Administrator stated to LPA that the file for C1 was not located at the facility.

During the health and safety check, LPA toured the building with Direct Support Staff, S2 including but not limited to common areas, bathrooms, bedrooms and outdoor area. Facility is noted to be clean and in good repair and clients in care appear to be safe. There are no imminent health/safety concerns on today's date. LPAs observed a wheelchair sitting in common area and two (2) clear bins sitting in common area. Administrator stated that C1 will not be returning.

Continued on LIC809C.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: DELL'S RESIDENTIAL HOME
FACILITY NUMBER: 075600400
VISIT DATE: 05/05/2023
NARRATIVE
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Continued from LIC809.

The following deficiency was observed and cited.
  • LPA observed C1's file was not located in the facility.

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/05/2023 11:34 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: DELL'S RESIDENTIAL HOME
FACILITY NUMBER: 075600400

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2023
Section Cited

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80070 Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.
This requirement is not met as evidenced by:
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Administrator agreed to review Regulation 80070 Client records and submit a self-certification that the regulation has been reviewed and administrator will abide by the regulation going forward. Self-certification will be submitted by the POC date.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having C1's record located at facility which poses a health and safety risk to persons 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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023
LIC809 (FAS) - (06/04)
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