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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200074
Report Date: 12/31/2024
Date Signed: 12/31/2024 12:44:54 PM

Document Has Been Signed on 12/31/2024 12:44 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:DELTA RESIDENTIAL-VINEYARDSFACILITY NUMBER:
079200074
ADMINISTRATOR/
DIRECTOR:		AARON & RYAN BUSALACCHIFACILITY TYPE:
735
ADDRESS:1280 CARPENTER ROADTELEPHONE:
(925) 679-1486
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 6DATE:
12/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Shiela MeiFelix, House managerTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On 12/31/2024 at 9:15AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced annual 1-Year required inspection. LPAs met with Shiela MeiFelix, House manager, and explained the purpose of the visit. Sheila called Administrator, Ryan Busalacchi to advise of visit. The administrator provided current certificate status via CCLD portal (#7034017735) that expires on 05/17/2026. The facility’s fire clearance was approved for six (6) non-ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of six (6) total bedrooms and three and a half (3 1/2) bathrooms. Three (3) bedrooms used by staff. There are no bodies of water. A comfortable temperature for clients is maintained at 75 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 107.5 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for clients. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last services on 01/29/2024. Fire drill last conducted 12/17/2024. Emergency Disaster Plane last reviewed on 01/04/2024. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/31/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: DELTA RESIDENTIAL-VINEYARDS
FACILITY NUMBER: 079200074
VISIT DATE: 12/31/2024
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Continued from LIC809.

Six (6) staff records were reviewed, and all staff have first aid certification. All Six (6) clients' records reviewed, current, and complete. LPA also reviewed P&I.

The following forms to be updated and submitted to CCLD by 01/07/2025:

· Liability insurance.
· Surety Bond
· LIC308 (Designation of facility Responsibility)
· LIC400 Affidavit Regarding Client/Resident Cash Resources
· Emergency disaster plan (9 pages)
· Updated LIC500 (Personnel Report)
· Updated facility sketch

LPA observed the following deficiencies:

At 9:53AM LPA observed during tour of the facility a missing doorknob on bedroom #2 door.
At 9:58AM LPA observed during tour of facility a broken handle on dishwasher located in kitchen.
At 10:01AM LPA observed during tour of the facility an unlocked cabinet with knives with a broken lock.


Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted and a copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 12/31/2024 12:44 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 12/31/2024 at 12:15 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: 12/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
80087 Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having knives in an unlocked cabinet with a broken lock located in the kitchen which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/01/2025
Plan of Correction
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Administrator agreed to replace broken lock and send an email photo of replacement lock to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 12/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/31/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 12/31/2024 12:44 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 12/31/2024 at 12:24 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: 12/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building 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 evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having a missing doorknob on clients' bedroom door and a broken handle on the dishwasher located in the kitchen which poses a potential safety or personal rights risk to persons in care.
POC Due Date: 01/07/2025
Plan of Correction
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Administrator agreed to repair and or replaced bedroom doorknob and dishwasher will send CCLD an email with photos of repairs and or replacement by POC date.
Section Cited
Deficient Practice Statement
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3
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POC Due Date:
Plan of Correction
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2
3
4
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:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 12/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/31/2024


LIC809 (FAS) - (06/04)
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