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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336403222
Report Date: 02/11/2025
Date Signed: 02/11/2025 11:04:22 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
02/05/2025 and conducted by Evaluator Abdoulaye Zerbo
COMPLAINT CONTROL NUMBER: 18-AS-20250205142238
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: 3DATE:
02/11/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mearlene MartinTIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Facility does not have a certified Administrator
Governing body is not active
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA)’s Janira Arreola and Abdoulaye Zerbo, conducted an unannounced visit to the facility in order to investigate the above allegations. LPAs met with Mearlene Martin who was informed of the purpose of the visit. LPAs conducted a walk through for a health and safety check, conducted interviews and records review.


It was alleged “Facility does not have a certified Administrator”. LPAs conducted a review of the department’s current and pending list of Administrator’s Certificates and found none for the current administrator.
LPA’s conducted a file review for the administrator and found there was no certificate at the facility. LPAs conducted an interview with the administrator which revealed they submitted their qualifications and check to the department (2) months ago but did not have proof the items sent. Therefore, based on interview and record review the allegation that the facility does not have a certified administor is substantiated.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
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 3
Control Number 18-AS-20250205142238
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: DELTA RESIDENTIAL HOME
FACILITY NUMBER: 336403222
VISIT DATE: 02/11/2025
NARRATIVE
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It was alleged that “Governing body is not active”, regarding the facility’s governing body being in a state of forfeiture with the Franchise Tax Bureau (FTB). LPAs conducted a file review which revealed the facility’s license is issued to entity Community Valley Homes INC. According to the Secretary of State website Community Valley Homes INC. has been in a state of forfeiture with the FTB as of 11/01/2024.
LPAs conducted an interview with the licensee which revealed their corporation is in good standing in the state of Nevada, but was unable to provide proof at the time of the visit. Therefore, based on interview and record review the allegation that the facility’s governing body is not active is substantiated.

Findings that are substantiated mean the preponderance of the evidence standard has been met. California Code of Regulations is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided Mearlene Martin.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20250205142238
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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: 02/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2025
Section Cited
CCR
85064(b)
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85064 Administrator Qualifications and Duties...(b) All adult residential facilities shall have a certified administrator. This requirement was not met as evidenced by:
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The licensee agreed to send proof of mailing their certificate's renewal and payment of the renewal by POC due date. Licensee agreed to designate a qualified Administrator and send notification of the designation by the POC due date
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Based on interview and record review the facility does not have a certified administrator at this time. This poses a potential health, safety, or personal rights risk to clients in care.
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Type B
02/14/2025
Section Cited
CCR
80063(a)(1)
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80063 Accountability
(a) The licensee, whether an individual or other entity, is accountable for the general supervision of the licensed facility, and…its operation. (1) If the licensee is a corporation or an association, the governing body shall be active and functioning in order to ensure such accountability. This requirement was not met as evidenced by:
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The licensee agreed to send proof of good standing with the FTB and have an active governing body by POC due date
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Based on interview and record review, the governing body is in a state of forfeiture and is not active as of 11/01/2024. This poses a potential health, safety, or personal rights isks to clients in care.
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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.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3