198603579-11-9-2023-28-AS-NGAA-CXES4R-20231109123309

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603579
Report Date: 11/09/2023
Date Signed: 11/09/2023 12:33:22 PM

Document Has Been Signed on 11/09/2023 12:33 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		FACILITY NUMBER:	198603579
ADMINISTRATOR:	MAXIMO, ROSAMARIA		FACILITY TYPE:	740
ADDRESS:	2433 ANGELA STREET		TELEPHONE:	(626) 912-3415
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91792
CAPACITY:	4	CENSUS: 4	DATE:	11/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	Rosamaria Maximo, Administrator		TIME COMPLETED:	12:35 PM

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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to DSP staff Jeffrey Sandejas. Administrator Rosamaria Maximo arrived shortly after. There are four (4) level 4C developmentally disabled adults; of which one is under age 59. The facility is vendored by San Gabriel/Pomona Regional Center.

Infection Control:

Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The facility has a COVID-19 Mitigation Plan and Infection Control Plan.

Operational Requirements:

The facility has a Dementia Waiver in place. A Hospice Waiver for 4 is approved.
A fire clearance for 4 non-ambulatory adults 60 and over; of which one (1) may be bedridden in room #1.
Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 6/20/2024.
Facility handles resident's money. A Surety Bond in the amount of $2,000 is in place.

See next page.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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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	FACILITY NUMBER: 198603579
	VISIT DATE: 11/09/2023

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Incident Medical and Dental:

Four (4) centrally stored resident medications were observed to have a 30-day supply of medications.
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:
One (1) resident is receiving home health services. No residents are enrolled in hospice services.
Postural support physician orders are on file.
No bed rails for mobility assistance were observed in resident beds.
Individual Service Plans and Appraisals were observed in resident files.
No residents have prohibited health conditions.

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

Exit interview was conducted with Administrator Rosamaria 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: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

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	FACILITY NUMBER: 198603579
	VISIT DATE: 11/09/2023

NARRATIVE

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Physical Plant/Environment Safety:

The facility is a single story home located in a residential neighborhood. The facility is staff operated and consists of 4 private resident bedrooms, office space, 2 bathrooms, living room, dining room, kitchen, outdoor patio area, laundry area in 2-car detached garage.
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 two (2) fully charged fire extinguishers and a fire pull alarm.
Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.

Staffing:

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

Resident Records/Incident Reports:

A total of four (4) resident files were reviewed. Files contained admission agreements, Physician's Reports, Appraisals, TB clearance, COVID-19 vaccine cards, Functional Capability Assessment, and emergency information.
RCFE complaint poster and Personal rights were observed posted in the facility entrance area.

Planned Activities:

Sufficient space to accommodate both indoor and outdoor activities was observed.
Indoor and outdoor activities are performed daily.
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.
No Physician orders for modified diets are in place.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 11/09/2023 12:33 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	FACILITY NUMBER: 198603579
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

PERSONNEL REQUIREMENTS - GENERAL All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that staff (S1 & S3) did not have current 1st Aid/CPR training on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/16/2023
	Plan of Correction
1 2 3 4	Submit a copy of S1 & S3's 1st Aid/CPR training card.

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: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4