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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200200
Report Date: 02/24/2025
Date Signed: 02/24/2025 03:52:15 PM

Document Has Been Signed on 02/24/2025 03:52 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/
DIRECTOR:		AARON / RYAN BUSALACCHIFACILITY TYPE:
735
ADDRESS:102 CELSIA WAYTELEPHONE:
(925) 420-6700
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 6DATE:
02/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:LEEROY NELSON, CARE STAFFTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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On 02/24/2025 at 1:15 PM, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced annual 1-year required inspection. LPA met with Leeroy Nelson, House Care Staff, and explained the purpose of the visit. At 1:36PM Edwin Isip, Supervisor arrived, The administrator currently holds a certificate (#7034017735) that expires on 05/17/2026. The facility’s fire clearance was approved for four (4) ambulatory and two (2) non-ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of nine (9) total bedrooms and three (31/2) bathrooms. three (3) staff bedrooms. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 71 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 109.3 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 01/10/2025. Fire drill last conducted 01/01/2025. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2025
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 3
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: 02/24/2025
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Continued from LIC809.

Four (4) staff records were reviewed, and all staff have first aid certification. Three (3) clients' records reviewed, current, and complete. LPA also reviewed P&I.

LPA observed the following:

· At 2:00PM LPA observed chemicals unlocked located in a bathroom.

The following forms to be updated and submitted to CCLD by 03/11/2025:
  • 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


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. A copy of this report and appeal rights was provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/24/2025 03:52 PM - It Cannot Be Edited


Created By: Carol Fowler On 02/24/2025 at 03:41 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: 02/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building 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 by having an unlocked cabinet in the clients bathroom which contained chemicals such as Downy sent boosters, woolite which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/25/2025
Plan of Correction
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Supervisor locked cabinet during the visit. DEFICIENCY CLEARED DURING VISIT.
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:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2025


LIC809 (FAS) - (06/04)
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