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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403222
Report Date: 05/19/2023
Date Signed: 05/19/2023 02:54:54 PM

Document Has Been Signed on 05/19/2023 02:54 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
RIVERSIDE ASC, 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:
05/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Donna Dill, CaregiverTIME COMPLETED:
03:05 PM
NARRATIVE
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On 5/19/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene was greeted and granted entry by Caregiver, Donna Dill who was informed of the purpose of visit. At the time of visit there was 2 staff and 2 residents present. LPA toured the facility inside and out with Donna.

Tour included:

Kitchen; LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. Utensils and dishware are sufficient for the approved capacity. The refrigerator and stove are in working order. Sharps are stored in a locked kitchen cabinet under the sink, available only to authorized individuals. Trash cans has tight-fitting lids. All need appliances were present and shown to be in working condition and clean. The fridge was measured at 40 degrees Fahrenheit and Freezer was measures at 0 degrees Fahrenheit.

Dining and Livingroom; LPA toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Temperature was 74 degrees Fahrenheit.



Hallway; LPA toured the hallway and observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance and record to be up to date. Carbon monoxide & smoke detector were tested and functioning properly. LPA observed additional linens and hygiene items.

Medications; LPA observed medications were labeled and stored in separate bins inside of a locked medication cabinet located in the kitchen and are distributed according to physician orders. The first aid kit was complete.



Continue on LIC809-C
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
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 5
Document Has Been Signed on 05/19/2023 02:54 PM - It Cannot Be Edited


Created By: Chinwe Nwogene On 05/19/2023 at 01:46 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: 05/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having an Infection Control Plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2023
Plan of Correction
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Donna stated an Infection Control Plan will be provided to LPA by the POC due date 5/29/2023.
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having cleaning solutions not adquatly secured which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2023
Plan of Correction
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LPA observed Donna lock up the laundry room. Donna stated a written statment of understanding of the regulation cited above will be provided to LPA by the POC due date 5/29/2023.
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:Joel Esquivel
LICENSING EVALUATOR NAME:Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/19/2023 02:54 PM - It Cannot Be Edited


Created By: Chinwe Nwogene On 05/19/2023 at 01:46 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: 05/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, 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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having the Hot water temperature at 134 degrees Fahrenheit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2023
Plan of Correction
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Donna stated a proof of the adjusted Hot water temperature will be provided to LPA by the POC due date 5/29/2023.
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having Night lights in the hallway which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2023
Plan of Correction
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Donna stated a picture of the night light will be provided to LPA by the POC due date 5/29/2023.
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:Joel Esquivel
LICENSING EVALUATOR NAME:Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/19/2023 02:54 PM - It Cannot Be Edited


Created By: Chinwe Nwogene On 05/19/2023 at 01:46 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: 05/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(12)(B)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not having a criminal record clearance or exemption documentation on file for staff #2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2023
Plan of Correction
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Donna stated a criminal record clearance or exemption documentation for staff #2 will be provided to LPA by POC due date 5/29/2023.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by not having documentation of first aid training for the identified three # staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2023
Plan of Correction
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Donna stated a proof of first aid training for the identified three # staff will be provided to LPA by POC due date 5/29/2023.
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:Joel Esquivel
LICENSING EVALUATOR NAME:Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/19/2023
NARRATIVE
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Continued from LIC809.

Bathroom; LPA toured hallway bathroom and observed bathroom to be clean and equipped with grab bar and non- slip mat. There is also a good number of personal toiletries available for the residents in care. The hot water measured at 134 degrees Fahrenheit which is over the regulatory limit. Citation will be issued.

Bedroom; LPA toured four #4 out of #4 residents bedroom and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs and lighting. LPA didn’t not observe nightlight. Citation will be issued.

Garage; LPA tour the garage and observed garage to be clean.

Laundry; LPA observed laundry room to be clean. Washing machine and dryer are all in good repair and sufficient for approved capacity. However, LPA observed laundry room was open, cleaning supplies were not adequately secured making it accessible to clients. Citation will be issued.

Backyard; LPA toured the backyard and observed backyard to be clean and furnitures in good condition. The backyard was free from obstruction and the side gate remain unlocked. No bodies of water were observed.

Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored and available to residents.

Records: All required postings, including COVID’s postings, were posted near the entryway and throughout the facility. The administrator certificate expires on 10/14/2023. All staff present has a criminal record clearance on file. Three #3 staff and #3 residents' records were reviewed. All three staff has no current CPR certification on file. One staff has no criminal record documentation file. LPA inquired about Infection Control Plan, LPA was told facility has no infection control. Four #4 citations will be issued.

Interview; Two #2 staff and two #2 resident where interviewed.

Therefore, based on the observations made during today’s visit, six #6 citations will be issued per Title 22, Division 6 of the California Code of Regulations. See LIC 809D. An exit interview was conducted, and this reported was provided along with appeal rights to Donna Dill.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC809 (FAS) - (06/04)
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