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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403222
Report Date: 05/09/2024
Date Signed: 05/09/2024 10:58:21 AM

Document Has Been Signed on 05/09/2024 10:58 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:
05/09/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Caregiver, Mearlene MartinTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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On 5/9/2024, Licensing Program Manager (LPM), Tricia Danielson and Licensing Program Analyst (LPA), Janette Romero made an unannounced visit at the facility to conduct a collateral visit. LPM and LPA met with Caregiver, Mearlene Martin, reviewed records and interviewed Client 1.

During today's visit, LPM and LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Caregiver Martin.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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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