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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200074
Report Date: 04/05/2023
Date Signed: 04/05/2023 02:37:44 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
09/16/2021 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20210916132752
FACILITY NAME:DELTA RESIDENTIAL-VINEYARDSFACILITY NUMBER:
079200074
ADMINISTRATOR:AARON & RYAN BUSALACCHIFACILITY TYPE:
735
ADDRESS:1280 CARPENTER ROADTELEPHONE:
(925) 679-1486
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY:6CENSUS: 6DATE:
04/05/2023
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:RYAN BUSALACCHI, Administrator TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Resident sustained unexplained injuries while in care
INVESTIGATION FINDINGS:
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On 04/05/2023 at 12:40PM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver findings for the above allegation. LPA met with Ryan Bussalachi and explained purpose of the visit.

Allegation: Resident sustained unexplained injuries while in care
Based on LPA’s observation on 09/23/2021, C1 had bruises on the back left of his shoulder blades, redness and skin peeling was also observed.

Civil penalty of $500.00 was issued on today’s date.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates 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.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023
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-20210916132752
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 RESIDENTIAL-VINEYARDS
FACILITY NUMBER: 079200074
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2023
Section Cited
CCR
80072(a)(2)
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Personal Rights. To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement is not met as evidence by:
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Administrator agreed to train all staff with the regulation cited above, a proof of training needs to be submitted to CCL office by POC date.
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Based on investigation, licensee did not comply with the section cited above, C1 sustained non- life-threatening injury, LPA observed bruises, redness and skin peeling on C1’s left shoulder which posed a potential health & safety risk to clients in care.
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$500.00 civil penalty was assessed during today's visit.
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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: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2