Community Care Licensing

Document Has Been Signed on 06/18/2024 02:31 PM - It Cannot Be Edited

FACILITY NAME:	DELTA RESIDENTIAL HOME		FACILITY NUMBER:	336403222
ADMINISTRATOR/ DIRECTOR:	MARY MARTIN		FACILITY TYPE:	735
ADDRESS:	11533 TRIUMPH LANE		TELEPHONE:	(951) 924-3364
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92557
CAPACITY: 6		CENSUS: 3	DATE:	06/18/2024
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:55 PM
MET WITH:	Mearlene Martin, Caregiver		TIME VISIT/ INSPECTION COMPLETED:	02:35 PM

SUPERVISORS NAME: Jazmond D Harris LICENSING EVALUATOR NAME: Yolanda Delgado LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024

Link to Parent Document Below:

FACILITY NAME: DELTA RESIDENTIAL HOME	FACILITY NUMBER: 336403222
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2024

Type B

Section Cited

CCR

85095.5(c)

(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
1 2 3 4	Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in no Infectional control observed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/25/2024
	Plan of Correction
1 2 3 4	Licensee will email a copy to LPA by POC due date

Type B

Section Cited

CCR

80087(a)

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in window screens that are torn or missing for the exterior windows need to be replaced which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/25/2024
	Plan of Correction
1 2 3 4	Licensee will replace window screens and email photographs to LPA by POC DUE DATE

SUPERVISOR'S NAME: Jazmond D Harris LICENSING EVALUATOR NAME: Yolanda Delgado LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024

Link to Parent Document Below:

FACILITY NAME: DELTA RESIDENTIAL HOME	FACILITY NUMBER: 336403222
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2024

Type B

Section Cited

CCR

85087.2(b)

(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in no shaded area observed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/25/2024
	Plan of Correction
1 2 3 4	Licensee will obtain shade and email photograph to LPA by POC due date

Type B

Section Cited

CCR

80066(a)(10)

(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: (10) A health screening as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in no health screening observed for S1 in file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/25/2024
	Plan of Correction
1 2 3 4	Licensee will obtain a health screening for S1 and email a copy to LPA by POC due date

SUPERVISOR'S NAME: Jazmond D Harris LICENSING EVALUATOR NAME: Yolanda Delgado LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024

Link to Parent Document Below:

FACILITY NAME: DELTA RESIDENTIAL HOME	FACILITY NUMBER: 336403222
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2024

Type B

Section Cited

CCR

80066(a)(11)

(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: (11) Tuberculosis test documents as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in no TB document for S1 observed in file which poses/posed a potential health, safety or personal rights risk persons in care.
	POC Due Date: 06/25/2024
	Plan of Correction
1 2 3 4	Licensee will obtain TB docs for S1 and email a copy to LPA by POC due date

Type B

Section Cited

CCR

80066(a)(12)(B)1

(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). 1. For Certified Administrators, a copy of their current and valid Administrator Certification meets this requirement. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in no Administrator cerficate in file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/25/2024
	Plan of Correction
1 2 3 4	Licensee wil emai a copy of the Administrator certificate to LPA by POC due date

SUPERVISOR'S NAME: Jazmond D Harris LICENSING EVALUATOR NAME: Yolanda Delgado LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024

Link to Parent Document Below:

FACILITY NAME: DELTA RESIDENTIAL HOME	FACILITY NUMBER: 336403222
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2024

Type B

Section Cited

CCR

85068.2(b)(1)(F)

(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (F) The written functional capabilities assessment specified in Section 80069.2. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in C1 did not have a current IPP which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/25/2024
	Plan of Correction
1 2 3 4	Licensee will obtain a current IPP and email a copy to LPA by POC due date

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Jazmond D Harris LICENSING EVALUATOR NAME: Yolanda Delgado LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024