<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201109
Report Date: 11/12/2021
Date Signed: 11/12/2021 03:15:44 PM

Document Has Been Signed on 11/12/2021 03:15 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-RIDGE CRESTFACILITY NUMBER:
079201109
ADMINISTRATOR:BUSALACCHI, AARONFACILITY TYPE:
735
ADDRESS:80 RIDGE CREST COURTTELEPHONE:
(925) 679-1486
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 5DATE:
11/12/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Liza Tagpis (house manager & Edwin Isip (supervisor) TIME COMPLETED:
03:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/12/2021 at 10:20 AM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct Pre-licensing required inspection. LPA met with facility manager, Liza Tagpis and supervisor Edwin Isip and explained the purpose of the visit. LPA called Ryan Busalachi one of the owners of the facility, per Ryan his brother Aaron Busalachi (Administrator) is not available due to medical reason. Ryan gave permission to LPA L. Ibo to discuss report to both Liza T. & Edwin Isip. Fire clearance is approved for 2 non-ambulatory on the first floor only, with approval total capacity of 6 ambulatory. The facility currently is licensed as a group home with 6 existing clients. However, facility is in the process of changing facility type and inspection is being conducted as a new Adult Residential Care Facility (ARF) facility.

LPA toured facility including but not limited to 6 clients' bedrooms, 1 staff room, 4.5 bathrooms, kitchen, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture. Linens and hygiene supplies were observed inside a cabinet. Room temperature was maintained at 70 degrees F and hot water temperature was maintained at 119.3 degrees F. Smoke detectors and carbon monoxide were operational. Two fire extinguishers was last serviced on February 2021.

Client's file and staff files were reviewed.

...Continued to LIC809C...
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2021
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: DELTA RESIDENTIAL-RIDGE CREST
FACILITY NUMBER: 079201109
VISIT DATE: 11/12/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The following will need to be completed before recommending licensure, LPA observed the following:

Incomplete First Aid kit
Sliding door blinds by the living room and dining area is broken and has some missing parts, LPA recommended that blinds needs to be replace.
Carpet on the master’s bedroom has torn and stained
Facility do not have night lights on the hallways and common bathrooms
Facility do not have operational Flashlight with batteries

LPA will return to conduct a re-inspection.

Component III is waived.

The existing Administrator Aaron Busalachi has been a Administrator for multiple homes for many years. The facility was clean, all records were cleared. Although facility has 6 existing clients, facility is in the process of changing facility type from a group home to Adult Residential Care Facility (ARF).

This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted with Edwin Isip and Liza Tagpis and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2