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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200074
Report Date: 09/23/2021
Date Signed: 09/23/2021 12:44:56 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: 5DATE:
09/23/2021
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Edwin IsipTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility is in disrepair, interior paint is peeling & resident's dresser is broken
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.

LPA observed the following, bedroom #1,2 & bedroom 3's wall's paint is peeling. C2’s dresser is broken (picture was taken during the visit).
...Continue to LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS 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)
Page: 2 of 6
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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Based on LPA interview and observation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. A copy of Appeal Rights and this report provided
SUPERVISORS 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)
Page: 3 of 6
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: 09/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2021
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds ...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 was not met as evidenced by:


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Administrator will purchase new dresser for C2 & will paint the walls that has paint peeling. Administrator will need to submit proof of correction by POC date.
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Based on interview & observation the Administrator failed to ensure the facility shall be clean, safe, sanitary and in good repair at all times, LPA observed broken dresser and wall painting peeling on bedroom 1,2 & 3, which poses a potential health and safety risk to the clients 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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6