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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200707
Report Date: 08/01/2023
Date Signed: 08/01/2023 12:40:20 PM

Document Has Been Signed on 08/01/2023 12:40 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:DELIA'S PLACEFACILITY NUMBER:
079200707
ADMINISTRATOR:RODRIGUEZ, JOSEFACILITY TYPE:
735
ADDRESS:1128 MONTEREY DRIVETELEPHONE:
(925) 529-0923
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 5DATE:
08/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Rosa Escorza, Direct Support ProfessionalTIME COMPLETED:
12:40 PM
NARRATIVE
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On 8/12/2023 at 10:00am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual 1-year required inspection. LPA met with Rosa Escorza, Direct Support Professional (DSP), and explained the purpose of the visit. DSP, Olivia Gonzalez, arrived at 10:18am. The administrator currently holds a certificate (#6018099735) that expires on 10/18/2024. 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 and back yard. The facility consists of four (4) bedrooms and two (2 ) bathrooms. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 74 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 80.0 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Bathrooms were equipped with non skid mats. Hand washing poster, 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 last serviced on 06/05/2022. Fire drill last conducted 6/1/2022. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2023
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: DELIA'S PLACE
FACILITY NUMBER: 079200707
VISIT DATE: 08/01/2023
NARRATIVE
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Continued from LIC809.

Four (4) staff records were reviewed, and all staff have first aid and CPR. All five (5) clients records were reviewed, current, and complete. LPA also reviewed P&I.
The following forms to be updated and submitted to CCLD by 8/8/2023:
  • LIC 400 Affidavit Regarding Client/Resident Cash Resources
  • LIC 402 Surety Bond
  • LIC 610D Emergency disaster plan
  • Liability insurance.
  • LIC500 (Personnel Record)
  • Client Roster

The following deficiencies were observed:

-At 10:05am, LPA observed S2 was not able to communicate with LPA.
-At 10:22am, LPA observed a lighter and screwdriver in unlocked kitchen drawer.
-At 10:30am, LPA observed hot water in shared bathroom at 80 degrees F.
-At 10:35am, LPA observed entry gate on right side of house locked with padlock.
-At 11:00am, LPA observed three (3) of five (5) clients were over the age 60.

*An immediate civil penalty of $500.00 will be assessed on today's visit.*

Exit interview conducted. A copy of LIC421M, appeal rights, and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 08/01/2023 12:40 PM - It Cannot Be Edited


Created By: Laura Hall On 08/01/2023 at 11:58 AM
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: DELIA'S PLACE
FACILITY NUMBER: 079200707

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2023

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 in having screwdriver and lighter is inaccessible to client which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2023
Plan of Correction
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Direct Support Staff immediately locked screwdriver and lighter in a locked kitchen cabinet. Deficiency cleared during visit.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 hot water between 105 and 120 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2023
Plan of Correction
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Administrator agreed to fix temperature of water to measure between 105 to 120 degree F. and submit photo of temperature 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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 08/01/2023 12:40 PM - It Cannot Be Edited


Created By: Laura Hall On 08/01/2023 at 11:58 AM
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: DELIA'S PLACE
FACILITY NUMBER: 079200707

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(h)
Health-Related Services
(h) There shall be at least one person capable of and responsible for communicating with emergency personnel in the facility at all times. The following information shall be readily available:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in having staff able to communicate in English with clients and LPA which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2023
Plan of Correction
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Additional staff arrived 15 minutes after LPA arrival. Deficiency cleared during visit.
Type B
Section Cited
CCR
85068.4(g)
85068.4 Acceptance and Retention Limitations

(g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having 50% of clients over 60 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2023
Plan of Correction
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Administrator agreed to submit exception request 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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/01/2023 12:40 PM - It Cannot Be Edited


Created By: Laura Hall On 08/01/2023 at 12:18 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: DELIA'S PLACE
FACILITY NUMBER: 079200707

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80072(7)
80072 Personal Rights

(7) Not to be locked in any room, building, or facility premises by day or night.

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 the entry gate unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2023
Plan of Correction
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Administrator agreed to have padlock removed from entry gate and submit photo to CCLD 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:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023


LIC809 (FAS) - (06/04)
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