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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336403222
Report Date: 10/28/2021
Date Signed: 10/28/2021 09:33:51 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/27/2020 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200127153314
FACILITY NAME:DELTA RESIDENTIAL HOMEFACILITY NUMBER:
336403222
ADMINISTRATOR:MARY MARTINFACILITY TYPE:
735
ADDRESS:11533 TRIUMPH LANETELEPHONE:
(951) 924-3364
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY:6CENSUS: 4DATE:
10/28/2021
ANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mary Martin, AdministratorTIME COMPLETED:
09:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is in disrepair
Facility failed to ensure resident's furniture/fixtures were in good repair
Facility is operating outside the scope of thier license
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Stephanie Torres, conducted an announced Regional Office meeting with Administrator, Mary Martin, for the purpose of delivering the findings of the above allegations. Martin was informed of the purpose of the meeting prior to this date.

Pertaining to the allegation, "Facility is in disrepair," the following was alleged: Sliding door in the back room does not open; garage door does not open; wooden emergency exit door does not open without obstruction, as it hits the cement; several holes observed throughout the house. The LPA initiated the investigation on January 29, 2020; the LPA conducted staff/client interviews, reviewed records, took copies of pertinent documentation, and toured the facility. During the facility tour, the following was observed: the sliding glass door opened without difficulty; the large garage door did not open; the exterior wooden door was observed to open without obstruction; two (2) holes observed in the bedroom of Client One (C1). Therefore, based on observation, this allegation is deemed SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 18-AS-20200127153314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DELTA RESIDENTIAL HOME
FACILITY NUMBER: 336403222
VISIT DATE: 10/28/2021
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
Regarding the allegation, "Facility failed to ensure resident's furniture/fixtures were in good repair," the following was alleged: lamp shades in consumers bedrooms are either burnt or broken; lamp stands do not have hooks for proper lamp shade installation; Client Two's (C2’s) night stand is missing knobs/handles; C2's headboard is not properly secured, two (2) dresser drawers do not close properly and the only light in the room flickers; Client Three's (C3's) room has poor lighting, an electrical outlet that does not work, dresser knobs that are not properly secured, broken blinds and a burned lamp shade; Client Four's (C4's) window is in need of blinds and their lamp has a broken lamp shade. During the facility tour, the following was observed: lamp shade in C1's room was observed to be torn all around the top of the cover, C3's night stand had missing handles, one (1) of C2's dresser drawers would not close completely, one (1), wall light was observed to flicker continuously, broken blinds in C3's bedroom. Therefore, based on observation, this allegation is deemed SUBSTANTIATED.

Pertaining to the allegation, "Facility is operating outside the scope of their license," it was alleged C4, who utilizes a walker to ambulate, is not appropriate to reside in the home due to it having only an Ambulatory fire clearance. On January 29, 2020, no medical assessment was available to identify the client's ambulatory status. Interviews revealed C1 does utilize a walker to ambulate, and the assistive device is not used as a preference. Therefore, based on interviews, this allegation is deemed SUBSTANTIATED.

A finding the complaint is substantiated means the allegation is valid because the preponderance of the evidence standard has been met. Citations will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 6).

An exit interview was conducted with Martin; this report was reviewed, and a copy provided along with LIC 811 and Appeal Rights.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20200127153314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DELTA RESIDENTIAL HOME
FACILITY NUMBER: 336403222
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2021
Section Cited
CCR
80087(a)
1
2
3
4
5
6
7
BUILDINGS AND GROUNDS: The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met, as evidenced by: Based on observation, the licensee did not ensure the facility was maintained in good
1
2
3
4
5
6
7
The Licensee stated photographic evidence will be issued to the Department by POC due date.
8
9
10
11
12
13
14
repair. The following was observed: 2 holes observed in the bedroom of C1. This poses a potential threat to the health, safety and personal rights of the client in care.
8
9
10
11
12
13
14
Type B
11/04/2021
Section Cited
CCR
80072(a)(2)
1
2
3
4
5
6
7
PERSONAL RIGHTS: ...Each client shall have personal rights which include, but are not limited to, the following: To be accorded safe, healthful & comfortable accommodations, furnishings & equipment to meet his/her needs. This requirement was not met, as evidenced by: Based on observation, the licensee did not
1
2
3
4
5
6
7
The Licensee stated photographic evidence will be issued to the Department by POC due date.
8
9
10
11
12
13
14
ensure clients were accorded comfortable furnishings & equipment. LPA observed: torn lamp shade, night stand missing handles, 1 dresser drawer wouldn't close completely, 1 wall light flickered, broken blinds. This poses a potential threat to the health, safety & personal rights of the clients in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20200127153314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: DELTA RESIDENTIAL HOME
FACILITY NUMBER: 336403222
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2021
Section Cited
CCR
80065
1
2
3
4
5
6
7
PERSONNEL REQUIREMENTS: Facility personnel shall be competent to provide the services necessary to meet individual client needs...This requirement was not met as evidenced by: Based on observation and interviews, the Licensee did not ensure staff were competent to provide the services
1
2
3
4
5
6
7
The Licensee stated a request for ambulatory change will be submitted to the Department by POC due date.
8
9
10
11
12
13
14
necessary to meet C4's needs. Photographs were obtained showing a walker in C4's possession. Staff/client interviews revealed C1 does utilize a walker to ambulate, and the assistive device is not used as a preference. This poses a potential threat to C4's health and safety.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/27/2020 and conducted by Evaluator Stephanie Torres
COMPLAINT CONTROL NUMBER: 18-AS-20200127153314

FACILITY NAME:DELTA RESIDENTIAL HOMEFACILITY NUMBER:
336403222
ADMINISTRATOR:MARY MARTINFACILITY TYPE:
735
ADDRESS:11533 TRIUMPH LANETELEPHONE:
(951) 924-3364
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY:6CENSUS: DATE:
10/28/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mary Martin, AdministratorTIME COMPLETED:
09:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not provide resident with an appropriate bed
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Stephanie Torres, conducted an announced Regional Office meeting with Administrator, Mary Martin, for the purpose of delivering the findings of the above allegations. Martin was informed of the purpose of the meeting prior to this date.

Regarding the allegation, "Facility did not provide resident with an appropriate bed," it was alleged the mattress of Client One (C1) was observed on the floor, after it had reportedly been broken by the client. On January 29, 2020 the LPA initiated the investigation; the LPA conducted staff/client interviews, reviewed records, took copies of pertinent documentation, and toured the facility. Photos were obtained which revealed C1's mattress was laying on the floor of their bedroom. The LPA observed, on January 29, 2020, C1 to have a mattress and bed frame, in good repair, available. Staff/client interviews could not provide a determination as to how long C1's mattress had remained on the floor of their bedroom. Therefore, due to a lack of information, this allegation is deemed UNSUBSTANTIATED at this time. An exit interview was conducted with Martin; this report was reviewed, and a copy was provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5