079200074-4-5-2023-15-AS-HHUL-CRWVKT-20230517163052

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200074
Report Date: 04/05/2023
Date Signed: 04/05/2023 02:44:30 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
06/09/2022 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20220609125047

FACILITY NAME:	DELTA RESIDENTIAL-VINEYARDS		FACILITY NUMBER:	079200074
ADMINISTRATOR:	AARON & RYAN BUSALACCHI		FACILITY TYPE:	735
ADDRESS:	1280 CARPENTER ROAD		TELEPHONE:	(925) 679-1486
CITY:	OAKLEY	STATE: CA	ZIP CODE:	94561
CAPACITY:	6	CENSUS: 6	DATE:	04/05/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	RYAN BUSALACCHI, Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not properly trained in transferring residents
Resident sustained injury due to improper transfers
Staff are not following residents nutrition plan
Insufficient staffing
Residents room has strong urine odor

INVESTIGATION FINDINGS:

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

On 4/5/2023 at 1:30PM Licensing Program Analyst (LPA) L. Ibo conducted an unannounced complaint visit to delivered investigation findings for the above allegations. LPA met with Administrator Ryan Busalacchi. LPA explained the purpose of the visit.

Allegation: Staff are not properly trained in transferring residents

Based on records review and interview with staff. The staff was trained by physical therapist to properly transfer client (C1). Individual service plan also stated that staff were trained to conduct exercise and proper transfer. Records review revealed that staff were trained on transfer assist for C1.

Continue to LIC9099C...

Unsubstantiated

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-20220609125047

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
	VISIT DATE: 04/05/2023

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: Resident sustained injury due to improper transfers

Based on staff interview and records review. There was no incident report pertaining to any injury on C1 due to improper transfer. Staff denied fall incident on C1 that may cause injury.

Allegation: Staff are not following residents’ nutrition plan

Records review from C1’s physician’s report revealed that C1 do not have a special diet plan. Staff was interviewed and staff stated that C1 can eat whatever he wants and most of the time he likes to eat sandwiches or breads.

Allegation: Insufficient staffing

LPA reviewed staff schedule for the facility, facility has 2-3 staff per shift available on schedule. Residents were observed calm and comfortable in their surroundings. LPA attempted to interview with clients in care, however clients are non-verbal and could not answer LPA’s question. Based on staff interview there is always 2-3 staff available on each shift and one awake staff at night.

Allegation: Residents room has strong urine odor

Based on LPA’s observation during several visit, facility is clean, organize and no strong urine odor on all the common areas, bathrooms and clients’ rooms.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conduct and a copy of this report provided.

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

LIC9099 (FAS) - (06/04)

Page: 2 of 2