079200074-9-6-2023-15-AS-KHOS-CVKRSX-20230911131727

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200074
Report Date: 09/06/2023
Date Signed: 09/06/2023 04:06:12 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
08/30/2023 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20230830150449

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:	09/06/2023
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Edwin Isip, Administrative Supervisor		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Physical Abuse

INVESTIGATION FINDINGS:

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On 9/6/23 at 3:00 p.m. Licensing Program Analyst (LPA) Greg Clark conducted an unannounced visit to open and deliver findings for the above allegation. LPA met with Edwin Isip, Administrative Supervisor and explained the purpose of the visit.

During the course of the investigation LPA interviewed the Reporting Party (RP), the Administrative Supervisor for the facility and day program staff (S1). LPA also reviewed R1’s facility file.

R1 has lived at the facility since February 2005 and is diagnosed with cerebral palsy is non-ambulatory and non-verbal with a history of emotional outbursts and uses a wheelchair for ambulation. R1’s Individual Program Plan (IPP) dated 7/12/22 states that R1 has “trouble with transitions.”

***report continues on LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

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-20230830150449

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: 09/06/2023

NARRATIVE

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***report continues from LIC9099***

LPA received a complaint alleging that there was an incident witnessed by day program staff where facility staff was getting her hair pulled by R1 and that facility staff (S2) twisted R1’s nose to get him to release his grip on her hair.

S2 stated that she used the re-direction strategy of giving R1 his iPad to get him to release his grip on her hair.

LPA was not able to interview R1 as he is non-verbal. There were no other witnesses to the incident.

This agency has investigated the complaint alleging physical abuse. We have found that the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC9099 (FAS) - (06/04)

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