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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403222
Report Date: 05/07/2024
Date Signed: 05/07/2024 04:15:31 PM

Document Has Been Signed on 05/07/2024 04:15 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/
DIRECTOR:
MARY MARTINFACILITY TYPE:
735
ADDRESS:11533 TRIUMPH LANETELEPHONE:
(951) 924-3364
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY: 6CENSUS: 3DATE:
05/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Donna Dill, CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA knocked at the door and there was no answer. LPA contacted Administrator Mary Martin and explained the reason for the visit; Mary will have someone respond. LPA received a call from Mary and that staff would need 30 minutes to come out to the facility. Staff arrived at the facility and was not able to gain entry and had to leave, staff returned and LPA was able to gain entry at 3:01 PM into the facility. LPA learned that three (3) clients reside at this facility; all at program and there are currently one (1) caregiver present. There is no Infection Control Plan on file.

Client Records-Incident Reports/Clients Rights-Information/Dental- LPA began review of client records. Three (3) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment-not current, and TB test results, needs and service plans-not current, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification.

Medications- are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately.



Due to time constraints, LPA will need to return to complete the Annual. Based on the information received during this visit today in the areas reviewed, deficiencies will need to be addressed.

This LIC 809 report was reviewed with the facility representative and a copy was provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2024
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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