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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201109
Report Date: 01/30/2024
Date Signed: 01/30/2024 02:09:18 PM

Document Has Been Signed on 01/30/2024 02:09 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:
01/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Liza Tagis, House ManagerTIME COMPLETED:
02:20 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 1/30/2024 at 12:15pm, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson conducted an unannounced annual 1-year required inspection visit. LPAs met with Liza Tagpis, House Manager and explained the purpose of the visit. The Administrator, Aaron Busalacchi, arrived at 12:50pm. 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 seven (7) bedrooms and three (3 ) bathrooms. One (1) bedroom is occupied by staff. All indoor and outdoor passageways are kept free of obstruction. There were no bodies of water observed. A comfortable temperature for clients is maintained at 70 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 128.1 degrees Fahrenheit. All toilets were in operating condition. 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 was last services on 01/29/2024. Fire drill last conducted 1/19/2024. Emergency disaster plan last updated 1/30/2024. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2024
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: DELTA RESIDENTIAL-RIDGE CREST
FACILITY NUMBER: 079201109
VISIT DATE: 01/30/2024
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
Continued from LIC809.

LPAs reviewed five (5) client files all were current and complete. LPAs reviewed four (4) staff files and all were up-to-date and complete.

The following forms to be updated and submitted to CCLD by 02/06/2024:
  • Liability insurance.
  • LIC500 (Personnel Record)
  • Client Roster
  • LIC308 (Designation of facility Responsibility)
  • Surety Bond


No deficiencies cited during visit.

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

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2