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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403222
Report Date: 02/11/2025
Date Signed: 02/11/2025 11:05:47 AM

Document Has Been Signed on 02/11/2025 11:05 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:
02/11/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Mearlene MartinTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
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Licensing Program Analysts (LPA)’s Janira Arreola and Abdoulaye Zerbo, conducted an unannounced visit to the facility to conduct a Plan of Correction (POC) Visit. The purpose of this report is to document the POCs that were previously agreed upon. LPAs met with Mearlene Martin who was informed of the purpose of the visit. LPAs conducted a walk through, conducted interviews and records review.

During Case Management Visit conducted on 11/05/2024 the facility was cited for CCR Section 85066(b) for not having a personnel roster. Licensee agreed to send proof of personnel roster by POC due date 11/12/2024.



During today’s visit it was confirmed with the licensee that the agreed upon POCs had not been submitted to the department by the POC due dates and had not been met. The time frame for POC inspection has lapsed, therefore the deficiencies will be re-cited on this report along with a new POC due date.

During today visit, it was observed that the hot water temperature was not measuring within regulations. The temperature was measured at 138.5 F in the client bathroom. A citation will be issued with a POC due date

An exit interview was conducted where this report along with the LIC809D page, and appeal rights were reviewed and provided.

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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/11/2025 11:05 AM - It Cannot Be Edited


Created By: Abdoulaye Zerbo On 02/11/2025 at 10:10 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: 02/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2025
Section Cited
CCR
85066(b)

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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:
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Licensee agreed to send proof of personnel roster by POC due date.
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Based on observation and interview, the licensee did have a personnel roster which poses a potential health, safety or personal rights risk to persons 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/11/2025 11:05 AM - It Cannot Be Edited


Created By: Abdoulaye Zerbo On 02/11/2025 at 10:13 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: 02/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/12/2025
Section Cited
CCR
80088(e)(1)

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80088
Furniture, Fixtures, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
This requirement is not met as evidenced by:
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Licensee agreed to have the maintenance adjust the temperature and send a video when mearsuring the temperature to LPA by POC due date
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Based on observation and interview, licensee did not meet this requirement evidenced by the hot water temperature measuring at 138.5 degrees, which poses an immediate health, safety or personal rights risk to persons 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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