336403222-2-20-2025-18-AS-JARA-DE3VY3-20250220155027

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336403222
Report Date: 02/20/2025
Date Signed: 02/20/2025 03:50:49 PM

Document Has Been Signed on 02/20/2025 03:50 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 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:	02/20/2025
TYPE OF VISIT:	POC	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:05 PM
MET WITH:	Staff, Mearlene Martin		TIME VISIT/ INSPECTION COMPLETED:	03:55 PM

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Licensing Program Analysts (LPA)’s Janira Arreola and Armando Perez, conducted an unannounced visit to the facility to conduct a Plan of Correction (POC) Visit. The purpose of this report is to document the POCs that were previously agreed upon. LPAs met with Staff, Mearlene Martin who was informed of the purpose of the visit. LPAs conducted a walk through, records review and interviews.

At the time of the visit there were (1) staff and (3) clients present. No immediate health or safety issues were observed.

The following deficiency were not corrected by the POC due date nor at the time of the visit. Civil Penalties are being assessed and will continue to accrue until correction has been submitted:

The facility was cited CCR Section 85066(b) for not having a personnel roster. The licensee agreed to send proof of personnel roster by POC due date 02/14/2025.

The facility was cited for 80088(e)(1) for hot water temperature not measuring within regulations. The temperature was measured at 138.5 F in the client bathroom. The POC was for the staff to send proof of water temperature within the required range by POC due date 02/12/2025.

A deficiency was cited for 85064(b) for not having a certified administrator, the licensee agreed to submit their renewal for Administrator’s certificate and designate a qualified administrator to the facility by the PoC due date of 2/14/2025.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

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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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: 02/20/2025

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A deficiency was cited for 80063(a)(1) for not having an active governing body, as Community Valley Homes INC. is in a stated of forfeiture with the Franchise Tax Bureau (FTB). The licensee agreed to submit documentation showing good standing with the FTB by the POC due date of 02/14/2025.

On today’s date LPAs conducted a walk through a recorded the hot water temperature at 139.2F at the beginning of the visit, and read again at 135F at the end of the visit in the client restroom. LPAs also requested the staff schedule which was not available at the time of the visit. LPAs spoke with the Licensee who stated that they would submit their administrator's recertification today and submit proof of good standing with the FTB by 5pm tomorrow 02/21/2025.

Therefore the POC has been met and was cleared at the time of the visit for the staff roster, FTB standing, and the administrator certification. Civil penalties are being assessed for the dates of 02/15/2025 to 02/20/2025 in the amount of $100 per day for 6 days. The hot water temperature civil penalty is being assessed from 2/13/2025 to 2/20/2025. The licensee was advised civil penalties will continue to accrue until the POC is submitted.

An exit interview was conducted where this report was reviewed and provided.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

LIC809 (FAS) - (06/04)

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