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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200074
Report Date: 01/04/2022
Date Signed: 01/04/2022 02:05:34 PM

Document Has Been Signed on 01/04/2022 02:05 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: 6DATE:
01/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Edwin Isip , Assistant Administrator TIME COMPLETED:
02:35 PM
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On 01/04/2022 Licensing Program Analyst (LPA) Leslie Ibo arrived unannounced to conduct an infection control annual required inspection. LPA met with Assistant Administrator Edwin Isip, LPA called Administrator Ryan Busalacchi was called to inform the purpose of the visit, Administrator is not available but gave permission to LPA to discuss and give copy the report to Assistant Administrator. Facility has census of 6.

LPA toured the facility inside and out including but not limited to common areas, resident rooms, bathrooms, kitchen and patio. Facility has enough supplies of PPEs, paper supplies and hygiene supplies. Medications are centrally stored in a locked area that is inaccessible to clients and refilled every at least 30 days.

Facility has enough 2-day perishable food and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE (mask). Facility has a mitigation plan and maintains record of routine screening for residents and staff.

No deficiency cited during the visit.

Exit interview conducted and copy of this report provided Edwin Isip- assistant administrator.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2022
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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