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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403222
Report Date: 06/22/2022
Date Signed: 06/22/2022 04:41:24 PM

Document Has Been Signed on 06/22/2022 04:41 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
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:
06/22/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Kim Grady, StaffTIME COMPLETED:
04:40 PM
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On 10/28/2021 LPA Torres issued citations to Licensee, Mary Martin, in relation to complaint #18-AS-20200127153314. No plans of correction (POCs) were received from Martin as of this date, so a POC visit was conducted.

The LPA observed the two (2) holes in the client bedroom closet to be repaired. The LPA observed the torn lamp shade to be removed and replaced with another light, the missing night stand handles to be replaced, the dresser drawer, which wouldn't close, was fixed, the flickering light was removed, and the broken blinds to be replaced with curtains.

The LPA has yet to receive any request for an ambulatory change from Licensee, Mamie Mary Martin. During the visit the LPA contacted Ms. Martin, though was unable to reach her. Staff available at time of visit could provide no information regarding the request. A citation and civil penalty will be issued due to this POC not being cleared by the Licensee.

An exit interview was conducted with Grady; 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: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2022
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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Document Has Been Signed on 06/22/2022 04:41 PM - It Cannot Be Edited


Created By: Stephanie Torres On 06/22/2022 at 02:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/24/2022
Section Cited
CCR
80065

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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
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The Licensee stated a request for ambulatory change will be submitted to the Department by 11/04/2021. No request for ambulatory change has yet to be received as of 06/22/22.
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necessary to meet C4's needs. Photographs were obtained showing a walker in C4's possession. Staff/client interviews revealed C4 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.
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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:Deborah Mullen
LICENSING EVALUATOR NAME:Stephanie Torres
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022


LIC809 (FAS) - (06/04)
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