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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200161
Report Date: 08/11/2022
Date Signed: 08/11/2022 02:21:42 PM

Document Has Been Signed on 08/11/2022 02:21 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-MAGNOLIA PARKFACILITY NUMBER:
079200161
ADMINISTRATOR:AARON/RYAN BUSALACCHIFACILITY TYPE:
735
ADDRESS:32 CALLA CT.TELEPHONE:
(925) 420-6700
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 6DATE:
08/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Edwin Isip, Assistant Administrator TIME COMPLETED:
02:35 PM
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On 8/11/2022 at 12:10 PM Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct an infection control annual inspection. LPA met with S1, LPA called Assistant Administrator Edwin Isip and inform him the purpose of the visit. At 12:50PM Administrator Ryan Busalacchi arrived at the facility. Facility has census of 6.

LPA toured the facility inside and outside. LPA observed 1 resident eating lunch, S1 stated that other residents are out and attending their day programs. Facility has enough supplies of PPEs, paper supplies and hygiene supplies. 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 infection control plan. Facility maintains record of routine screening for residents and staff. Visitors policy is posted on the front entrance.

There was at least 7 days of nonperishable and 2 days of perishable foods. Smoke and Carbon monoxide detectors were operational. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. Medications are centrally stored in a locked area that is inaccessible to clients and refilled every at least 30 days. Smoke detectors and carbon monoxide were in operating condition during visit.

...Continue to LIC809...

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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-MAGNOLIA PARK
FACILITY NUMBER: 079200161
VISIT DATE: 08/11/2022
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Infection control designated leader is the Administrator, Assistant Administrator Edwin Isip and House manager S3. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation.

No deficiency cited during the visit.

Exit interview conducted. Copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC809 (FAS) - (06/04)
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