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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200074
Report Date: 06/14/2022
Date Signed: 06/14/2022 05:18:38 PM

Document Has Been Signed on 06/14/2022 05:18 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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: 5DATE:
06/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Edwin Isip, Assistant Administrator TIME COMPLETED:
05:45 PM
NARRATIVE
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On 6/14/2022 Licensing Program Analyst (LPA) Leslie Ibo conducted unannounced case management visit while conducting a complaint investigation. LPA informed Edwin I. the purpose of the visit.

LPA observed the following:
C1 sustained less serious injury (bruises/abrasion) while in care.
Open electrical outlet observed on room 1.
Failure to report C1’s fall incident.
Broken cabinet dresser observed on room three.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099D. Failure to submit proof of corrections (POCs) by plan of correction due dates along with the LIC9098 Proof of Correction and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided to Assistant Administrator Edwin Isip.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/14/2022 05:18 PM - It Cannot Be Edited


Created By: Leslie Ibo On 06/14/2022 at 03:48 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: DELTA RESIDENTIAL-VINEYARDS
FACILITY NUMBER: 079200074

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/16/2022
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement is not met as evidence by:
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Assistant administrator agreed to submit copy of staff training regarding care and supervision. Copy of training topic, name and signature of staff needs to be submitted to CCL office by 6/16/2022.
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Based on interviews and observation, licensee failed to provide supervision needs for C1, which resulted for C1’s fall on the bathroom and resulted to C1’s bruises on her face. Needs and appraisal needs also indicated that C1’s needs assistance in bathing. These posed immediate safety and health risks to the clients in care.
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A $500.00 civil penalty is assessed today and will continue for $100.00 per day until corrected.

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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 Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/14/2022 05:18 PM - It Cannot Be Edited


Created By: Leslie Ibo On 06/14/2022 at 03:52 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: DELTA RESIDENTIAL-VINEYARDS
FACILITY NUMBER: 079200074

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/24/2022
Section Cited
CCR
80087(a)

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Buildings and Grounds (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 evidence by:

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Assistant Administratot agreed to fix or replace cabinet dresser and fix or replace open electrical outlet and to send picture to LPA by POC due date.
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Based on observation, LPA observed broken cabinet drawer on room three and open electrical outlet on room one, which posed potential health and safety risk to residents in care.
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Type B
06/24/2022
Section Cited
CCR80061(b)(1)(E)

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Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event (1) Events reported shall include the following: (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
This requirement is not met as evidence by:
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Assistant adminstrator agreed to train all staff regarding the regulation cited above. Proof of training with staff name and signature needs to be submitted to CCL office by POC due date.
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Based on interview, licensee did not comply with the above Regulation by failing to submit incident reports regarding C1’s fall to which poses potential health, safety and personal right risks 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 Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022


LIC809 (FAS) - (06/04)
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