198603577-10-3-2023-28-AS-NGAA-CW9RNF-20231003131013

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603577
Report Date: 10/03/2023
Date Signed: 10/03/2023 01:10:23 PM

Document Has Been Signed on 10/03/2023 01:10 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	DELTA HOME CARE III		FACILITY NUMBER:	198603577
ADMINISTRATOR:	ROSAMARIA MAXIMO		FACILITY TYPE:	740
ADDRESS:	2400 ANGELA ST.		TELEPHONE:	(626) 912-3454
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91792
CAPACITY:	4	CENSUS: 4	DATE:	10/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:04 AM
MET WITH:	Rose Maximo		TIME COMPLETED:	01:15 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

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Assistant Administrator Danielle Maximo. Administrator Rose Maximo arrived later. There are currently 4 developmentally disabled residents 60 years and older residing in the facility. None of the residents are receiving hospice care, home health, or have Dementia. The inspection was completed using the CARE tools. Twelve (12) CARE tools domains were reviewed.

Infection Control:

Visitors are no longer being screened for COVID-19, but are still required to sign in. The facility has an Infection Control Plan and Covid-19 Mitigation Plan. Infection control practices and Personal Protective Equipment (PPEs) were observed.

Operational Requirements:

A current Plan of Operation was reviewed.
The facility has a Dementia Waiver in place. A Hospice Waiver for 4 is approved.
A fire clearance for 6 non-ambulatory adults 60 and over is in place.
Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current.
Facility handles resident's P & I monies. A Surety Bond of $2,000 is current.

***See next page for report narrative.***

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

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 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DELTA HOME CARE III	FACILITY NUMBER: 198603577
	VISIT DATE: 10/03/2023

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

Physical Plant/Environment Safety:

The facility is a single story home located in a residential neighborhood consisting of 4 private resident bedrooms, 2 bathrooms, living room, dining room/kitchen, outdoor patio area with patio furniture, and 2 car detached garage with laundry area.
The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Kitchen drawers containing knives/sharp objects were locked.
The facility has one (1) fully charged fire extinguisher and a fire pull alarm. Auditory alarms in bedrooms with exterior exit doors are operable.
Water temperature readings did not measure within the required 105 - 120 degrees Fahrenheit. Bathrooms hot water measured 123.1 & 122.6 Degrees Fahrenheit. Citation was issued.

Staffing:

A total of 7 staff provide care and supervision to the clients.

Personnel Records/Staff Training:

Administrator certificate expired 7/10/2022. Licensee/Administrator provided proof that training was submitted to certification unit and is awaiting receipt of current certificate.
Personnel files were reviewed. Criminal Background Clearance, staff training, 1st Aid/CPR, and health screening/TB clearance was checked.

Resident Records/Incident Reports:

A total of four (4) resident files were reviewed. All required documents were observed.
RCFE complaint poster and Personal rights were observed posted in the facility.

***narrative continues next page***

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DELTA HOME CARE III	FACILITY NUMBER: 198603577
	VISIT DATE: 10/03/2023

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

Planned Activities:

Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed, as well as community outings.
The facility does not have a Resident Council.

Food Service:

Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.
Physician orders for modified diets are in place. One (1) resident has a puree diet.

Incident Medical and Dental:

Medication Administration Records (MARs) and resident medications were reviewed. PRN medications were not listed on the MAR, but MD orders are in place. Administrator was advised to contact pharmacy so they can add the PRN medications to the MAR.
Medical and dental transportation is provided by facility staff.

Disaster Preparedness:

Emergency and Disaster Plan LIC 610E is in place.
The last emergency disaster drill was conducted on 9/22/2023.

Residents with Special Health Needs:

No residents currently receive hospice or home health care.
No resident beds have bed rails..
No residents have prohibited health conditions.

Per California Code of Regulations, Title 22, deficiencies were cited.

Exit interview was conducted with Administrator Rose Maximo. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 10/03/2023 01:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DELTA HOME CARE III	FACILITY NUMBER: 198603577
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that the hot water in the bathrooms measured 123.1 & 122.6 Degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/04/2023
	Plan of Correction
1 2 3 4	Administrator agreed to submit a hot water temperature log that shows staff tested the water during every shift today and tomorrow.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 10/03/2023 01:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DELTA HOME CARE III	FACILITY NUMBER: 198603577
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that bedroom #4 has broken mini blinds and no curtains on the window, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/17/2023
	Plan of Correction
1 2 3 4	Administrator shall submit picture proof that bedroom #4's mini blinds have been repaired and/or purchased new.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

Page: 5 of 5