<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075650106
Report Date: 03/18/2022
Date Signed: 03/18/2022 12:58:44 PM

Document Has Been Signed on 03/18/2022 12:58 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:DELTA RESIDENTIAL - STONY HILLFACILITY NUMBER:
075650106
ADMINISTRATOR:BUSALACCHI, AARON & RYANFACILITY TYPE:
730
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 6CENSUS: 5DATE:
03/18/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Supervisor Edwin Isip, House Manager Maria Tan, Administrator Ryan BusalacchiTIME COMPLETED:
01:15 PM
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
On 3/18/22 at 9:48AM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility for a case management - annual continuation. LPA met with Supervisor Edwin Isip, Facility Manager Maria Tan, and Administrator Ryan Busalacchi and informed of the purpose of the visit. Safety precautions were taken, including mask-wearing, entry screening, and pre-visit screening call.

During the initial inspection on 3/07/22, LPA inspected the facility and grounds and facility and personnel files using the CARES Inspection Tool. LPA continued with the tool to complete the inspection of resident records on 3/11/22. Today's visit is to complete and the deliver the report.

At visit, LPA re-toured the facility and updated observations of deficiencies listed below. The following was observed: The facility living and meal prep spaces are clean and sanitary; the facility's first aid kit was observed to be complete; personal rights were posted; facility license was posted; smoke detectors are in working condition; water and room temperature measured within permitted ranges.
The following deficiencies were observed on 3/7/22 and/or 3/11/22 (See attached LIC 809-D pages):
1) Two (2) unsecured jugs of laundry detergent were observed on the floor in the corner of resident R2's (See attached LIC 811) bedroom. LPA issued a citation of California Code of Regulations (CCR) Section 80087(g). Laundry detergent jugs were immediately removed from the room and placed with locked chemicals.
2) Laundry detergent was stored among food items all accessible to resident R2 as they were stored unsecured in R2's bedroom. LPA issued a citation of CCR Section 80087(i). The laundry detergent jugs were removed, and R2 was moved out of this room by 3/18/22.
3) The storage loft in resident R2's bedroom has no full wall separating the spaces, so R2's bedroom is joint with staff "room" in the loft, meaning staff and resident shared a bedroom. LPA issued a citation of CCR Section 84087(b)(6). R2 was moved out of this room by 3/18/22.
4) More than 10 bottles of empty, expired, or discontinued medications were observed in a locked cabinet in the kitchen, including psychotropic medications, and at least one psychotropic that expired in November...
SUPERVISORS NAME: Zaid Hakim
LICENSING EVALUATOR NAME: Mariah Hawkins
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 2 of 23
Document Has Been Signed on 03/18/2022 12:58 PM - It Cannot Be Edited


Created By: Mariah Hawkins On 03/11/2022 at 02:04 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: DELTA RESIDENTIAL - STONY HILL
FACILITY NUMBER: 075650106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, licensee did not ensure cleaning solutions were inaccessible to residents due to unsecured jugs of laundry detergent being observed on the floor in the corner of resident R2's bedroom. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2022
Plan of Correction
1
2
3
4
Facility immediately removed items during initial visit on 3/7/22.
Type A
Section Cited
CCR
80087(i)
Buildings and Grounds
(i) The items specified in Section 80087(g) above shall not be stored in food storage areas or in storage areas used by or for clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, licensee did not ensure cleaning solutions were not stored in food storage areas due to laundry detergent being stored among food items all accessible to resident R2 as they were stored unsecured in R2's bedroom. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2022
Plan of Correction
1
2
3
4
Facility removed all food and cleaning solutions stored in R2's bedroom following the initial visit on 3/7/22.
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:Zaid Hakim
LICENSING EVALUATOR NAME:Mariah Hawkins
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022


LIC809 (FAS) - (06/04)
Page: 4 of 23
Document Has Been Signed on 03/18/2022 12:58 PM - It Cannot Be Edited


Created By: Mariah Hawkins On 03/11/2022 at 02:04 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: DELTA RESIDENTIAL - STONY HILL
FACILITY NUMBER: 075650106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
84087(b)(6)
Buildings and Grounds
(b) Bedrooms shall meet, at a minimum, the following requirements: (6) Except for infants, children shall not share a bedroom with an adult.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, licensee did not ensure staff and residents did not share a room due to storage loft in resident R2's (see LIC 811) bedroom having no full wall separating spaces and bedroom being joint with staff "room" in the loft. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2022
Plan of Correction
1
2
3
4
The facility has moved staff out of the storage loft and resident to hallway bedroom.
Type A
Section Cited
CCR
80075(l)
Health-Related Services
(l) Prescription medications which are not taken with the client upon termination of services, or which are not to be retained shall be destroyed by the facility administrator, or a designated substitute, and one other adult who is not a client.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, licensee did not ensure medications were properly destroyed due to there being more than 10 bottles of empty, expired, or discontinued medications in a locked cabinet in the kitchen, including psychotropic medic- -ations, and at least one psychotropic expired in November 2021 and was filled in 2020. Supervisor and Facility Manager confirmed these should have been destroyed. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2022
Plan of Correction
1
2
3
4
Facility agrees to properly dispose of all expired and discontinued medication and medication bottles and update the medication destruction records, which will be submitted to LPA by 3/21/22. Please note the different due date from other citations.
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:Zaid Hakim
LICENSING EVALUATOR NAME:Mariah Hawkins
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022


LIC809 (FAS) - (06/04)
Page: 6 of 23
Document Has Been Signed on 03/18/2022 12:58 PM - It Cannot Be Edited


Created By: Mariah Hawkins On 03/11/2022 at 02:04 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: DELTA RESIDENTIAL - STONY HILL
FACILITY NUMBER: 075650106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(1)
Food Service
(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan -Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, licensee did not ensure all food was quality due to there being in the kitchen a bulk stack of peanut butter each with an inch of separated oil and dated "Best before Oct 17 2020" as well as a large jug of chicken flavoring with real chicken in ingredients dated "Jan 29 22." This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2022
Plan of Correction
1
2
3
4
Facility removed items immediately. Facility replaced peanut butter with supply that was in date.
Type B
Section Cited
CCR
80076(a)(5)
Food Service
(5) Menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days. Menus shall be made available for review by the clients or their authorized representatives and the licensing agency upon request.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, licensee did not ensure menus as served were maintained due to facility having only rotation of planned menus and no saved menus to reflect what was served in case it differed from the planned menu. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2022
Plan of Correction
1
2
3
4
Facility agrees to begin logging the served menus for each week to reflect what was fed to residents at facility. Facility will submit each week's menu for the weeks of 3/20/22 and 3/27/22 by due date.
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:Zaid Hakim
LICENSING EVALUATOR NAME:Mariah Hawkins
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022


LIC809 (FAS) - (06/04)
Page: 8 of 23
Document Has Been Signed on 03/18/2022 12:58 PM - It Cannot Be Edited


Created By: Mariah Hawkins On 03/11/2022 at 02:04 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: DELTA RESIDENTIAL - STONY HILL
FACILITY NUMBER: 075650106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
84087(b)(4)
Buildings and Grounds
(b) Bedrooms shall meet, at a minimum, the following requirements: (4) No room commonly used for other purposes shall be used as a bedroom.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, licensee did not ensure no room commonly used for other purposes was not used as a bedroom due to attached storage loft with low ceiling and accessed by narrow, ladder-like staircase in resident R2's room being used as a staff bedroom for live-in staff member. The facility was previously advised of this requirement on 4/19/19. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2022
Plan of Correction
1
2
3
4
Facility has moved staff member out of storage loft.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. 

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview, licensee did not ensure emergency drills were conducted quarterly due to staff S1 (see LIC 811) stating disaster drills are conducted twice a year but that two drills were conducted in 2020, one in 2021, and none so far in 2022. Logs were located for only 3/31/20, 12/17/20, and 9/3/21. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2022
Plan of Correction
1
2
3
4
Facility agrees to submit the schedule of the projected dates for quarterly drills for 2022 and to submit documentation of a drill conducted following this visit and prior to due date of 4/4/22.
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:Zaid Hakim
LICENSING EVALUATOR NAME:Mariah Hawkins
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022


LIC809 (FAS) - (06/04)
Page: 3 of 23
Document Has Been Signed on 03/18/2022 12:58 PM - It Cannot Be Edited


Created By: Mariah Hawkins On 03/11/2022 at 02:04 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: DELTA RESIDENTIAL - STONY HILL
FACILITY NUMBER: 075650106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
84361(f)
Documentation and Reporting Requirements
(f) The licensee must maintain a monthly log of each use of manual restraints. The log must include:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview, the licensee did not maintain a monthly log of manual restraints due to there being no log and manual restraints having been used. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2022
Plan of Correction
1
2
3
4
Facility agrees to develop a manual restraint log and submit the logs for January to March 2022 to LPA Hawkins by due date.
Type B
Section Cited
CCR
84065(i)
Personnel Requirements
(i) Notwithstanding Sections 80065(f)(1) through (6), new child care staff hired on or after July 1, 1999, shall complete a minimum of 24 hours of initial training comprised of the 8 and 16 hour training as specified in (1) and (2) below:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not ensure staff initial training was completed/documented due to staff files for S1, S3, S4, S5 (see LIC 811) having incomplete or missing initial training logs. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2022
Plan of Correction
1
2
3
4
Facility agrees to develop a plan with a training calendar to retrain staff S1, S3, S4, S5 on the missing sections of their initial training and complete updated initial training records. Plan will be sent to LPA Hawkins by due date and training logs will be sent to LPA upon completion.
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:Zaid Hakim
LICENSING EVALUATOR NAME:Mariah Hawkins
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022


LIC809 (FAS) - (06/04)
Page: 19 of 23
Document Has Been Signed on 03/18/2022 12:58 PM - It Cannot Be Edited


Created By: Mariah Hawkins On 03/11/2022 at 02:04 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: DELTA RESIDENTIAL - STONY HILL
FACILITY NUMBER: 075650106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
84065(j)(1)
Personnel Requirements
(1) Notwithstanding Sections 80065(f)(1) through (6), all child care staff shall complete a minimum of 20 hours of annual training, except as specified in (2) below.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview, the licensee did not ensure staff met the 20hr training requirement due to staff records indicating less than 20hrs and there being no training record or training certificates for training in 2021 for staff S1, S2, S3, S4, S5 (see LIC 811). This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2022
Plan of Correction
1
2
3
4
Facility agrees to develop a calendar for 2022 with specific dates for trainings, including the required outside training hours per the regulation, and to submit this training calendar to LPA Hawkins by due date.
Type B
Section Cited
CCR
80070(b)(6)
Client Records
(b) Each record must contain information including, but not limited to, the following: (6) A signed copy of the admission agreement specified in Section 80068.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview, the licensee did not ensure to maintain admission agreement due to files for residents R2, R3, R5 (see LIC 811) missing admission agreements. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2022
Plan of Correction
1
2
3
4
Facility agrees to obtain the missing admission agreements and/or generate new ones as well as to hold a training for management on the importance of having admission agreements signed at admission, even if youth move between sister facilities (under the same licensee) or if placement agency does not furnish their own form. The admissiong agreement forms and training material and verification of training will be sent to LPA Hawkins by due date.
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:Zaid Hakim
LICENSING EVALUATOR NAME:Mariah Hawkins
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022


LIC809 (FAS) - (06/04)
Page: 14 of 23
Document Has Been Signed on 03/18/2022 12:58 PM - It Cannot Be Edited


Created By: Mariah Hawkins On 03/11/2022 at 02:04 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: DELTA RESIDENTIAL - STONY HILL
FACILITY NUMBER: 075650106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
84070(b)(11)
Children's Records
(b) The following information regarding the child shall be obtained and maintained in the child's record: (11) A copy of the standard appraisal form specified in Section 84068.1(b)(1)(C), if used.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not maintain appraisal or needs and services plans / individualized program plans due to files for residents R1, R3, R4, R5 (see LIC 811) either missing plans or having plans 2+ years old. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2022
Plan of Correction
1
2
3
4
Facility Manager was able to find in their email and print the IPPs for all residents. Facilty agrees to update the needs and services plans for all residents for staff reference and hold a training of management staff on the importance of maintaining plans in files in order for staff to refer to and implement the care plan. Training documentation and verification will be sent to LPA by due date.
Type B
Section Cited
CCR
84070(b)(12)
Children's Records
(b) The following information regarding the child shall be obtained and maintained in the child's record: (12) A copy of the current court order, or written authorization of the child's parent or guardian, for each psychotropic medication, as defined in Section 84001(p)(4).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview, the licensee did not maintain psychotropic consent documentation due to this documentation not being found by LPA or present staff in files for residents R1, R4, R5. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2022
Plan of Correction
1
2
3
4
Facility agrees to obtain psychotropic medication consent forms signed by residents' authorized representatives and submit forms for each resident to LPA Hawkins by due date.
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:Zaid Hakim
LICENSING EVALUATOR NAME:Mariah Hawkins
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022


LIC809 (FAS) - (06/04)
Page: 11 of 23
Document Has Been Signed on 03/18/2022 12:58 PM - It Cannot Be Edited


Created By: Mariah Hawkins On 03/11/2022 at 02:04 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: DELTA RESIDENTIAL - STONY HILL
FACILITY NUMBER: 075650106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
84070(b)(13)
Children's Records
(b) The following information regarding the child shall be obtained and maintained in the child's record: (13) A separate log for each psychotropic medication prescribed to the child documenting all the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and observation, the licensee did not ensure there was a separate log for each psychotropic medication due to all resident records containing joint medication administration records on a version of the LIC 622A rather than the LIC 622B (or version of form) for psychotropic medication. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2022
Plan of Correction
1
2
3
4
Facility agrees to hold an all-staff training on medication administration records and logging psychotropic medications on a separate log and to begin using a separate log for psychotrpic medications by 4/1/22. The staff training confirmation sign-in sheet and the medication administration records for all residents and all medications will be sent to LPA Hawkins by 4/4/22.
Type B
Section Cited
CCR
80075(k)(6)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (6) No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not ensure that medications were not transferred between containers due to staff S1 (see LIC 811) stating that they keep old medication bottles, remove the label, and transfer medications to that container for residents' home visits, with no dates of incidents. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2022
Plan of Correction
1
2
3
4
Facility agrees to properly dispose of all expired and discontinued medication and medication bottles, update the medication destruction records, and ammend the program statement (PS) medical/dental section specific to destruction of medication, to identify a responsible person and develop schedule for checking for medications needing to be destroyed in order to ensure timely destruction. Updated medication destruction records and PS ammendment will be submitted to LPA Hawkins by 4/4/22.
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:Zaid Hakim
LICENSING EVALUATOR NAME:Mariah Hawkins
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022


LIC809 (FAS) - (06/04)
Page: 18 of 23
Document Has Been Signed on 03/18/2022 12:58 PM - It Cannot Be Edited


Created By: Mariah Hawkins On 03/11/2022 at 02:04 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: DELTA RESIDENTIAL - STONY HILL
FACILITY NUMBER: 075650106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)
Safeguards for Cash Resources, Personal Property, and Valuables
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, observation, and interview with House Manager, licensee did not ensure inventory of property due to the LIC 621 for property/valuables inventory missing for residents R1, R5 (See LIC 811) and not updated for 2021/2022 for R2, R3, R4. This poses/posed a potential health, safety, or personal rights risk to residents in care.
POC Due Date: 04/04/2022
Plan of Correction
1
2
3
4
Facility agrees to generate updated LIC 621 records for residents R1, R2, R3, R4, and R5 and send as one package to LPA Hawkins by due date.
Type B
Section Cited
CCR
84087(b)(5)
(b) Bedrooms shall meet, at a minimum, the following requirements: (5) No bedroom shall be used as a public or general passageway to another room, bath or toilet.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, licensee did not ensure that no bedroom was used as a general passageway to another room due to resident R2's (See LIC 811) bedroom being the only way to access a ladder-like staircase to the storage loft being used as a staff room for live-in staff member. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2022
Plan of Correction
1
2
3
4
The facility has moved staff out of the storage loft and resident to hallway bedroom.
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:Zaid Hakim
LICENSING EVALUATOR NAME:Mariah Hawkins
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022


LIC809 (FAS) - (06/04)
Page: 7 of 23
Document Has Been Signed on 03/18/2022 12:58 PM - It Cannot Be Edited


Created By: Mariah Hawkins On 03/17/2022 at 05:47 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: DELTA RESIDENTIAL - STONY HILL
FACILITY NUMBER: 075650106

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, licensee did not ensure the facility was clean and in good repair due to resident R1's (see LIC 811) room being dirty with unsanitary floor and old food, plates, and containers in drawers; smoke detector is unsecured and hanging by wires from living room ceiling; hallway bathroom is missing a shower curtain. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2022
Plan of Correction
1
2
3
4
Facility replaced shower rod and curtain, secured smoke detector, and cleaned R2's room. Facility agrees to submit training materials and post-training quizes and/or signed confirmation of understanding for each staff regarding personnel duty (see CCR Section 84065.2(e)(2)) to complete household duties even if a child refuses to participate. These will be submitted by due date of 4/4/22.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Zaid Hakim
LICENSING EVALUATOR NAME:Mariah Hawkins
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022


LIC809 (FAS) - (06/04)
Page: 20 of 23
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: DELTA RESIDENTIAL - STONY HILL
FACILITY NUMBER: 075650106
VISIT DATE: 03/18/2022
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
... 2021 and was filled in 2020. Supervisor and Facility Manager confirmed these should have been destroyed. LPA issued a citation of CCR Section 80075(I).
5) In the kitchen was a bulk stack of peanut butter each with an inch of separated oil and dated "Best before Oct 17 2020" as well as a large jug of chicken flavoring with real chicken in ingredients dated "Jan 29 22." LPA issued a citation of CCR Section 80076(a)(1). Peanut butter and chicken flavoring were removed immediately.
6) The facility uses only a rotation of planned menus and has no saved menus to reflect what was served in case it differed from the planned menu. LPA issued a citation of CCR Section 80076(a)(5).
7) The attached storage loft with low ceiling and accessed by narrow, ladder-like staircase in resident R2's bedroom was observed to be used as a staff bedroom for live-in staff member. The facility was previously cited and advised of the requirement to not use the storage space as a bedroom on 4/19/19. LPA issed a citation of CCR Section 84087(b)(4). R2 was moved out of this room by 3/18/22, and the storage space is no longer being used as a staff bedroom.
8) Facility Manager stated disaster drills are conducted twice a year and that two drills were conducted in 2020, one in 2021, and none so far in 2022. Logs were located for only 3/31/20, 12/17/20, and 9/3/21. LPA issued a citation of Health and Safety Code (HSC) Section 1565(c), which requires quarterly drills.
9) Supervisor and Facility Manager confirmed that restraints have been performed at the facility in the past 6 months but there was no log of manual restraints. LPA issued a citation of CCR Section 84361(f).
10) Staff files for S1, S3, S4, S5 (see LIC 811-C) were observed to have incomplete or missing initial training logs. LPA issued a citation of CCR Section 84065(i).
11) Staff files indicate that less than 20hrs of annual training was received in 2021 and no training record or training certificate for training in 2021 for staff S1, S2, S3, S4, S5 were observed in the files. LPA issued a citation of CCR Section 84065(j)(1).
12) The files for residents R2, R3, R5 were observed to be missing admission agreements, and Supervisor and Facility Manager were not able to locate all missing admission agreements. LPA issued a citation of CCR Section 80070(b)(6).
13) The files for residents R1, R3, R4, R5 were observed to be either missing needs and services and/or behaviorist/Regional Center treatment plans or having plans 2+ years old. LPA issued a citation of CCR Section 84070(b)(11).
14) The files for residents R1, R4, R5 were observed to be missing psychotropic medication consent documentation. LPA issued a citation of CCR Section 84070(b)(12).
15) The medication administration records (MARs) for residents R1, R4, R5 were observed to log...
SUPERVISORS NAME: Zaid Hakim
LICENSING EVALUATOR NAME: Mariah Hawkins
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC809 (FAS) - (06/04)
Page: 22 of 23
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: DELTA RESIDENTIAL - STONY HILL
FACILITY NUMBER: 075650106
VISIT DATE: 03/18/2022
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
... psychotropic and non-psychotropic medications jointly rather than psychotropic medications being logged separately on the (or version of) LIC 622B Psychotropic MAR (PMAR). LPA issued a citation of CCR Section 84070(b)(13).
16) Facility Manager stated that the facility keeps old medication bottles, removes the labels, and uses them to transfer medications to that container for residents' home visits. LPA issued a citation of CCR Section 80075(k)(6).
17) The files for residents R1, R5 were missing property/valuables inventory, and the inventories were not updated for 2021/2022 for R2, R3, R4. Facility Manager confirmed that items had since been removed or added, such as shoes or holiday gifts. LPA issued a citation of CCR Section 80026(h).
18) LPA observed that the licensee did not ensure that no bedroom was used as a general passageway to another room due to resident R2's bedroom being the only way to access a ladder-like staircase to the storage loft being used as a staff room for live-in staff member. LPA issued a citation of CCR Section 84087(b)(5). R2 was moved out of the room by 3/18/22, and the storage loft is no longer being used as a staff bedroom.
19) LPA observed that the licensee did not ensure the facility was clean and in good repair due to: smoke detector hanging by wires in the living room; hallway bathroom missing shower curtain and rod; resident R1's bedroom dirty with unsanitary floor, two dirty food containers and spoon on desk, crumbs on all furniture and in crevices, crumbs and wet and dried unknown substances on the floor from the doorway to the closet to the bed, candy wrapper, bowl of dried applesauce, plate with left over crust and residual oil/liquid on plate in the closet, 18 eaten yogurt cups in dresser drawer, two plates, spoon, and 2 hot dog buns in another drawer, cheese wrappers, empty Ensure drink bottle, empty jar of parmesan cheese in another drawer. Facility Manager stated the rooms are cleaned daily and that R1 makes this mess in one day. LPA issued a citation of CCR Section 80087(a). Shower curtain and rod replaced and R1's room cleaned by 3/11/22, and smoke detector secured by 3/18/22.

LPA advised of the following deficiencies (See attached LIC9102 pages):
1) LPA observed that complaint procedures were not posted in the facility. LPA advised of this requirement, per CCR Section 84072.2(a)(3). Complaint procedures posted by 3/18/22.
2) LPA observed that emergency drills were not conducted quarterly as required and that documentation of drills was not available in the facility records. Facility Manager had to locate the logs from their computer and had difficulty locating them all. LPA advised, per CCR Section 80023(d)(2), that all logs be maintained at the facility site in either an electronic file accessible to licensing personnel during all visits or in the physical...
SUPERVISORS NAME: Zaid Hakim
LICENSING EVALUATOR NAME: Mariah Hawkins
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC809 (FAS) - (06/04)
Page: 23 of 23
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: DELTA RESIDENTIAL - STONY HILL
FACILITY NUMBER: 075650106
VISIT DATE: 03/18/2022
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
... facility files.
3) LPA observed that all staff files were missing work performance evaluations. Supervisor stated that performance evaluations are maintained in the confidential files at the administrative office. LPA advised, per CCR Section 84066(b)(6), that the facility maintain a record of work performance evaluations and also that per Section 80066(e)(1), the facility ensure all personnel records are accessible at/from the facility site.
4) During visit on 3/7/22, LPA observed that there were confidential client documents scattered and disorganized on a table in the garage. During visit on 3/11/22, LPA observed that staff left the laundry room open as well as the garage door while two residents were present and walking around the facility. Residents could have entered the garage and grabbed the documents, which LPA discussed with Facility Manager. Having the documents disorganized and outside of the proper secured file storage area does not encourage maintenance of confidentiality of documentation. LPA advises, per CCR Section 80070(c), that the facility ensure the garage door is kept closed and locked while residents are at the facility and that the facility remove and properly store the client documents currently in the garage. Garage was cleaned by 3/18/22.
5) LPA observed that residents R1 and R3 files were missing signed medical care consent forms. LPA advises, per CCR Section 84070(b)(10), that the facility ensure consent forms are signed by the authorized representative at admission.
6) LPA observed that needs and services and treatment plans were missing from the files and the plans that were in some of the residents' files were more than a year old, which was discussed with Facility Manager and Supervisor. LPA advises, per 84068.3(a), that needs and services should be maintained and should be updated at least every six months.
7) LPA observed that the facility did not maintain documentation of bedroom sharing arrangements. LPA advised, per CCR Section 84087(e), that the facility begin documenting bedroom sharing and that residents are compatible and maintain this documentation in the file of each child sharing a bedroom.

An exit interview was conducted, and a copy of this report was left with Administrator Ryan , whose signature on this form confirms receipt.
SUPERVISORS NAME: Zaid Hakim
LICENSING EVALUATOR NAME: Mariah Hawkins
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC809 (FAS) - (06/04)
Page: 21 of 23