079200074-9-23-2021-15-AS-KHOS-CQYQ3V-20230417114916

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200074
Report Date: 09/23/2021
Date Signed: 09/23/2021 12:44:56 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
09/16/2021 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20210916132752

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: 5	DATE:	09/23/2021
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Edwin Isip		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility does not have a sufficient quantity of food

INVESTIGATION FINDINGS:

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On 9/23/2021 at around 9:05 AM Licensing Program Analyst (LPA) L. Ibo visited the facility in order to meet the 10-day requirement for notification of the above allegations. LPA L. Ibo met with S1, assistant administrator, Administrator was called to inform the purpose of the visit, Per Administrator he is not available and S1 will handle the visit for today. LPA explained that the reason for the visit is to S1 that a complaint has been received and an investigation will be conducted on these allegations.

LPA L. Ibo requested the following documents; physician report, LIC500, staff schedule, client roster and special incident reports, staff training's. LPA toured the facility inside and out. LPA checked facility’s common areas such as but not limited to, client’s bedroom, kitchen, living room, bathrooms and backyard.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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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
	VISIT DATE: 09/23/2021

NARRATIVE

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LPA observed during the visit that there is sufficient quantity of food. The pantries, refrigerators and freezer
are well stocked with food supplies for clients in care. According to S1 the facility Administrator buys groceries at least once a week, S1 also goes to food bank to get food supplies at least once a week.

The Department has investigated these allegations and based upon LPA observations & interviews conducted the allegation is found to be unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation has occurred.

Exit interview conducted with S1 and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021

LIC9099 (FAS) - (06/04)

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