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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200161
Report Date: 08/06/2024
Date Signed: 08/06/2024 01:44:58 PM

Document Has Been Signed on 08/06/2024 01:44 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-MAGNOLIA PARKFACILITY NUMBER:
079200161
ADMINISTRATOR/
DIRECTOR:		AARON/RYAN BUSALACCHIFACILITY TYPE:
735
ADDRESS:32 CALLA CT.TELEPHONE:
(925) 420-6700
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 6DATE:
08/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Felicito Macalino, House Manager/CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:55 PM
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On 08/06/2024 at 9:30am, Licensing Program Analyst (LPA)T.Syess-Gibson conducted an unannounced annual 1-Year required inspection. LPA met with Felicito Macalino, Caregiver, and explained the purpose of the visit. Administrator, arrived at approximately 10:15am The administrator currently holds a certificate (#7032310735) that expires on 04/12/2026. The facility’s fire clearance was approved for six (6) ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of six (6) total bedrooms and three and a half (3 1/2) bathrooms. One (1) bedroom used by staff. All indoor passageways are kept free of obstruction. LPA observed a pool in the back yard behind a locked gate . 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 106.5 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 residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 01/29/2024. Fire Drill last conducted on 05/17/2024. Emergency Disaster Plan was last posted on 03/13/2024. First aid kit was observed to be complete.

Continued LIC809C

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024
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-MAGNOLIA PARK
FACILITY NUMBER: 079200161
VISIT DATE: 08/06/2024
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Continued from LIC809.

Five (5) staff records were reviewed, and all staff have first aid certification. All Six (6) clients' records reviewed, current, and complete. LPA reviewed P&I and medications.

The following forms to be updated and submitted to CCLD by 08/13/2024:

· Liability insurance.
· Surety Bond
· LIC500 (Personnel Record)
· Client Roster
· LIC308 (Designation of facility Responsibility)
· LIC400 Affidavit Regarding Client/Resident Cash Resources
· LIC610D Emergency Disaster Plan
· Administrator Certificate

LPA observed the following deficiencies:

· At 9:50 AM, LPA observed laundry room door off hinges and leaning against the wall inside the laundry room.
· At 10:09 AM, LPA observed on the side of the house a chair, bike, lawn mower, broom, empty crate and trash can which is obstructing the passageway of the emergency exit.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. 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. A copy the appeal rights and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/06/2024 01:44 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 08/06/2024 at 12:43 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-MAGNOLIA PARK
FACILITY NUMBER: 079200161

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
80087 Buildings 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 not having laundry room door on hinges, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2024
Plan of Correction
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Administrator repaired laundry room door during visit. Deficiency cleared during visit
Type B
Section Cited
CCR
80087(c)
80087 Buildings and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction

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 bike, chair, lawn mower,, empty crate and garbage bin on passageway to emergency exit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2024
Plan of Correction
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Administrator agreed to remove all objects from passageway and send a photo of cleared passageway via email to CCLD by POC date.
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: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024


LIC809 (FAS) - (06/04)
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