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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200200
Report Date: 02/16/2023
Date Signed: 02/16/2023 02:23:16 PM

Document Has Been Signed on 02/16/2023 02:23 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-LEGENDSFACILITY NUMBER:
079200200
ADMINISTRATOR:AARON / RYAN BUSALACCHIFACILITY TYPE:
735
ADDRESS:102 CELSIA WAYTELEPHONE:
(925) 420-6700
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 6DATE:
02/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Edwin Isip, facility supervisorTIME COMPLETED:
02:40 PM
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On 02/17/2023 at 12:35PM Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct an infection control annual inspection. LPA met with Supervisor Edwin Isip and manager Frances Nelson, LPA explained the purpose of the visit. Facility has census of 6.

LPA toured the facility with manager Frances. including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility has nine bedrooms and 3.5 bathrooms. Three bedroom is reserved for staff use only. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Visitors’ policy is posted on the front entrance. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. 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.

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. Facility has a mitigation plan and maintains record of routine screening for residents and staff.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2023
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: DELTA RESIDENTIAL-LEGENDS
FACILITY NUMBER: 079200200
VISIT DATE: 02/16/2023
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LPA observed the following:

· At 12:38PM LPA observed that room #4's door has a cracked in the middle part.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted with supervisor Edwin Isip and manager France Nelson. A copy of this report and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/16/2023 02:23 PM - It Cannot Be Edited


Created By: Leslie Ibo On 02/16/2023 at 01:41 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-LEGENDS
FACILITY NUMBER: 079200200

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
(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 failed to maintain the facility in good repair where the bedroom #4 door was observed to have cracked in the middle part of it, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2023
Plan of Correction
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Supservisor Edwin stated that Administrator will replaced the door within this week. LPA asked supervisor to send a proof of correction to CCL 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:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023


LIC809 (FAS) - (06/04)
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