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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200200
Report Date: 03/07/2024
Date Signed: 03/07/2024 06:00:56 PM

Document Has Been Signed on 03/07/2024 06:00 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-LEGENDSFACILITY NUMBER:
079200200
ADMINISTRATOR:AARON / RYAN BUSALACCHIFACILITY TYPE:
735
ADDRESS:102 CELSIA WAYTELEPHONE:
(925) 420-6700
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 6DATE:
03/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Frances Nelson House ManagerTIME COMPLETED:
06:10 PM
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On 03/07/2024 at 3:45 PM, Licensing Program Analysts (LPAs) L. Hall and Tonica Syess-Gibson conducted an unannounced annual 1-year required inspection. LPAs met with Frances Nelson, House manager, and explained the purpose of the visit. At 3:57PM Frances called Administrator, Aaron Busala to advise of visit. The administrator currently holds a certificate (#6009236735) that expires on 04/9/2024. The facility’s fire clearance was approved for four (4) ambulatory and two (2) non-ambulatory clients.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of ten (10) total bedrooms and three (3 ) bathrooms. Four (4) bedrooms used by staff. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 69 degrees Fahrenheit. LPAs 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 113.8 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/carbon monoxide were in operating condition during visit. Fire extinguisher was last services on 01/29/2024. Fire drill last conducted 02/21/2024. 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: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: DELTA RESIDENTIAL-LEGENDS
FACILITY NUMBER: 079200200
VISIT DATE: 03/07/2024
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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. LPAs also reviewed P&I.

The following forms to be updated and submitted to CCLD by 03/13/2024:
  • 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


No deficiencies cited during visit.

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

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC809 (FAS) - (06/04)
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