<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600912
Report Date: 08/13/2024
Date Signed: 08/13/2024 10:41:40 AM


Document Has Been Signed on 08/13/2024 10:41 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:DELIA'S RETIREMENT HOME, INCFACILITY NUMBER:
415600912
ADMINISTRATOR:CHUA, DELIA J.FACILITY TYPE:
740
ADDRESS:52 ARLINGTON DRIVETELEPHONE:
(650) 757-1768
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 4DATE:
08/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Delia ChuaTIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 8/13/24, Licensing Program Analyst (LPA) Grace Donato conducted a case management visit concerning a report received. LPA met with Administrator Delia Chua. LPA explained the purpose of today's visit.

LPA received a report from facility on 8/01/24 that on July 30, 2024 at 8:30am, in the bathroom, R1 stood up from the commode to transfer the wheelchair. R1 was off balance so instead of falling to the floor. Staff pulled R1 up to stand up but accidentally bang his left eye to the wall and got cut on the edge of his eye.

LPA interviewed R1 and it was mentioned that R1 is happy and has no complaints here in the facility. LPA observed the resident to be watching tv and eating popcorn.

During the visit, it was found out that a caregiver did not report to Licensee that there was another incident that happened last June 2024 but was not reported to licensing. Although it was not reported to Licensing, staff still called 911 and R1 was sent to hospital. Staff also called the responsible party.

Deficiency is cited today as the Licensee did not report an incident that happened to R1 on June 2024.

Deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed and copy of this report and the Appeal Rights are provided.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/13/2024 10:41 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: DELIA'S RETIREMENT HOME, INC
FACILITY NUMBER: 415600912

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/14/2024
Section Cited
CCR
87211(a)(1)(D)

1
2
3
4
5
6
7
87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1)A written report shall be submitted ... (D) Any incident which threatens the welfare, safety or health of any resident...
1
2
3
4
5
6
7
Licensee will develop a plan to ensure compliance and the plan will include staff training. Licensee to submit to LPA by POC deadline.
8
9
10
11
12
13
14
This was not met as evidenced by: Based on interview and records review, caregiver did not report to Licensee an incident that happened to R1 on June 2024, and Licensee was not able to report to Licensing, which poses an immediate health, safety, or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2