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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403222
Report Date: 11/05/2024
Date Signed: 11/05/2024 11:53:41 AM

Document Has Been Signed on 11/05/2024 11:53 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 HOMEFACILITY NUMBER:
336403222
ADMINISTRATOR/
DIRECTOR:		MARY MARTINFACILITY TYPE:
735
ADDRESS:11533 TRIUMPH LANETELEPHONE:
(951) 924-3364
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 6CENSUS: 3DATE:
11/05/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Mearlene MartinTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs),Abdoulaye Zerbo and Armando Perez conducted an unannounced visit to the facility for a health an safety check. The LPAs met with Manager Mearlene Martin, and informed her of the purpose for the visit and were granted access.

The facility is a single story building and consists of one (1) staff room, four (1) resident bedrooms and two (2) bathrooms. There are currently (3) residents in care. LPAs toured the facility for the purpose of a health and safety check. LPAs observed two exits blocked in the activity room. A citation will be given.

LPAs were not able to obtain the LIC 500 and LIC 9050 as the facility did not have them on site. A citation will be issued. LPAs observed current personnel to be fingerprint cleared and listed on the facility's personnel report.

An exit interview was conducted, and a copy of this report was provided to facility manager Mearlene Martin.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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 11/05/2024 11:53 AM - It Cannot Be Edited


Created By: Abdoulaye Zerbo On 11/05/2024 at 11:28 AM
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: 11/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/12/2024
Section Cited
HSC
85066(b)(1)(2)(3)(4)

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85066 Personnel Records

(b) A dated employee time schedule shall be developed at least monthly, shall be displayed conveniently for employee reference and shall contain the following information for each employee:

(1) Name.

(2) Job title.

(3) Hours of work.

(4)Days off.
This requirement is not met as evidenced by:
Based on observation and interview, the licensee did not comply with the section cited above in one of one file, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Licensee agreed to send proof of personel roster by POC due date.
Type B
11/12/2024
Section Cited
HSC
87307(d)(6)

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87307 Personal Accommodations and Services
(d) The following space and safety provisions shall apply to all facilities:
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidenced by:
Based on observation and interview, the licensee did not comply with the section cited above in one of one activity room. LPAs observed both exits to be blocked by furnitures in the activity room, which poses/posed a potential health, safety or personal rights risk to persons in care.

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Licensee agreed to send proof of correction by POC due date

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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:Rikesha Stamps
LICENSING EVALUATOR NAME:Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2