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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 04:24:18 PM

Document Has Been Signed on 06/22/2022 04:24 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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Kim Grady, StaffTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA), Stephanie Torres, made an unannounced visit to the facility to conduct an annual inspection, with an emphasis on infection control. The LPA arrived at approximately 02:15 PM, signed in and utilized hand sanitizer. The LPA met with Staff, Kim Grady, and informed her of the purpose of her visit. There are currently no cases of COVID-19 within the facility.

During today's visit, the LPA toured the home and made observations pertaining to the facility's infection control measures. The LPA observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, proper use of face coverings, and sufficient Personal Protective Equipment (PPE). The facility submitted the COVID-19 Mitigation Plan, which is currently under review by the Department.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, Chapter 1 or 6 of the California Code of Regulations. An exit interview to review this report was conducted with Grady and a copy of this report was provided.
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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