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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403222
Report Date: 03/26/2024
Date Signed: 03/26/2024 02:35:02 PM


Document Has Been Signed on 03/26/2024 02:35 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:
03/26/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Mamie Mary Martin - Licensee/AdministratorTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Crystal Colvin and Licensing Program Manager (LPM) Tricia Danielson met with Licensee/Administrator Mamie Mary Martin at the Riverside Adult and Senior Care Regional Office for the purpose of discussing ongoing concerns with the facility. Also in attendance at the meeting was Consumer Program Liaison Jessica Zarate, Consumer Program Liaison Zachary Hardin, and Program Manager Minerva De La Rosa with Inland Regional Center (IRC). Below is a summary of what was discussed:

Outstanding Licensing Fees

Statement Made Regarding Possible Financial Distress

Lack of Certified Administrator for Facility

Licensee/Administrator Mamie Mary Martin was provided with a time frame to remedy these issues. Licensee to have items discussed corrected by 3/29/24. The Department is additionally requesting a Staff Roster for the facility to be submitted directly to LPA Colvin along with documents to appoint a designated Administrator to the facility. License/Administrator Mamie Mary Martin was informed that if these items are not corrected by the provided date, that deficiencies and/or civil penalties will be assessed.

An exit interview was conducted, and a copy of this report was provided to Licensee/Administrator Mamie Mary Martin.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024
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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