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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005566
Report Date: 09/22/2022
Date Signed: 09/22/2022 02:22:56 PM


Document Has Been Signed on 09/22/2022 02:22 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:A1 RCFE @ DELPHINEFACILITY NUMBER:
306005566
ADMINISTRATOR:VILLARMINO, SHIRLEYFACILITY TYPE:
740
ADDRESS:923 HUGGINS AVETELEPHONE:
(714) 399-5040
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:6CENSUS: 6DATE:
09/22/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Shirley HillsTIME COMPLETED:
02:30 PM
NARRATIVE
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On this date Licensing Program Analyst (LPA) Claudia Gutierrez conducted a complaint investigation. During the course of the visit, LPA took a guided tour of the facility with Administator (AD) Shirley Hills.

During the guided tour LPA observed a bed in the walk-in closet of bedroom 4. AD stated that the walk-in closet located in bedroom 4 is a staff bedroom. Bedroom 4 is currently occupied by two residents. Per California Code of Regulations 87307(a)(C) Personal Accommodations and Services, The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility, no bedroom of a resident shall be used as a passageway to another room or toilet.

Per observations by LPA and interviews conducted with AD and Staff 1 (S1) LPA determined the facility is not providing comfortable living accommodations and privacy for the residents as a resident bedroom is being used as a passageway to another room; a deficiency was cited on this date.

An exit interview was conducted with AD. A copy of this report and appeal rights was left at the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
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 2


Document Has Been Signed on 09/22/2022 02:22 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: A1 RCFE @ DELPHINE
FACILITY NUMBER: 306005566

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/22/2022
Section Cited

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Personal Accommodations and Services
(a) The facility shall be large enough to provide comfortable living accommodations and privacy for the residents (C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet.

This requirement was not met as evidence by;
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Per observations made by LPA and interviews conducted with AD and Staff 1 (S1), LPA determined the facility is not providing comfortable living accommodations and privacy for the residents as a resident bedroom is being used as a passageway to another room.
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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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
LIC809 (FAS) - (06/04)
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