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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201109
Report Date: 12/18/2024
Date Signed: 12/18/2024 01:25:08 PM

Document Has Been Signed on 12/18/2024 01:25 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:DELTA RESIDENTIAL-RIDGE CRESTFACILITY NUMBER:
079201109
ADMINISTRATOR/
DIRECTOR:		BUSALACCHI, AARONFACILITY TYPE:
735
ADDRESS:80 RIDGE CREST COURTTELEPHONE:
(925) 679-1486
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 4DATE:
12/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH: Liza Tagpis, House ManagerTIME VISIT/
INSPECTION COMPLETED:
01:41 PM
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On 12/18/2024 at 11:10am, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced annual 1-Year required inspection visit. LPA met with Liza Tagpis, House Manager and explained the purpose of the visit. House Manager contacted Administrator via telephone to advise of visit. Administrator, Aaron Busalacchi currently holds a certificate #7032310735. 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 four and half (4 1/2 ) 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 73 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 122.9 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 clients. 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 12/05/2024. Emergency disaster plan last updated 01/02/2024. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: DELTA RESIDENTIAL-RIDGE CREST
FACILITY NUMBER: 079201109
VISIT DATE: 12/18/2024
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Continued from LIC809.

LPA reviewed four (4) client files all were current and complete. LPA reviewed four (4) staff files and all were up-to-date and complete. LPA reviewed a sample of medications during visit.

The following forms to be updated and submitted to CCLD by 12/25/2024:
  • 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: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
LIC809 (FAS) - (06/04)
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