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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201109
Report Date: 12/01/2022
Date Signed: 12/01/2022 05:59:20 PM

Document Has Been Signed on 12/01/2022 05:59 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: 6DATE:
12/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Edwin Isip, backup Administrator and Liza Tagpis, house manager TIME COMPLETED:
06:15 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 12/1/2022 at 4:45 PM Licensing Program Analyst (LPA) Leslie Ibo arrived unannounced to conduct an annual required inspection. LPA met with back-up Administrator Edwin Isip. Facility has census of 6.

LPA toured the facility with Edwin Isip, back-up Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. 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 clients. Visitors policy is posted on the front entrance. Clients’ 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 infection control plant. Facility maintains record of routine screening for clients and staff.

No deficiency cited during the visit.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2022
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 1