480107184-3-24-2025-21-AS-ADEZ-DF3T4H-20250324142355

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 480107184
Report Date: 03/24/2025
Date Signed: 03/24/2025 02:24:22 PM

Document Has Been Signed on 03/24/2025 02:24 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	DELTA MEADOWS CARE HOME		FACILITY NUMBER:	480107184
ADMINISTRATOR/ DIRECTOR:	CECILIA GANZON		FACILITY TYPE:	740
ADDRESS:	101 O'BRIEN CIRCLE		TELEPHONE:	(707) 647-1759
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94589
CAPACITY: 5		CENSUS: 4	DATE:	03/24/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:16 AM
MET WITH:	Administrator Cecilia Ganzon		TIME VISIT/ INSPECTION COMPLETED:	02:33 PM

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	At approximately 09:15AM, Licensing Program Analyst (LPA) Ali Deniz made an unannounced annual inspection of this licensed senior care facility. LPA met with facility caregiver Romulo Cancino, Administrator Cecilia Ganzon arrived later before the inspection started. There is a total of 4 residents at facility, one with dementia, and one resident on hospice. Facility is a 1 story building with 4 Resident bedrooms, 2 bathrooms, and common spaces. At approximately 9:45AM, LPA/Administrator toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Staff were in the process of cleaning up the rooms at the time of this inspection. Toxins are stored in a locked in housekeeping closet in the hallway. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Water temperature measured within regulation between 105- and 120-degrees F at faucets accessible to residents. Fire extinguishers inspected were charged on 02/17/2025. Smoke and carbon monoxide detectors were present and in-order. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure. At approximately 10:05AM, LPA reviewed three staff records. 1 of 3 records did not contain documentation of LIC501 (Personal records), LIC503 (Health Screening) and TB test (Technical Violation Issued). Administrator agrees to complete missing documents for S1. 3 out of 3 staff didn’t complete their 20 initial hours training as required (Technical Violation Issued). Evidence of current first aid and CPR training were current for all the staff. Continued LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Ali Deniz
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025

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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Document Has Been Signed on 03/24/2025 02:24 PM - It Cannot Be Edited

Created By: Ali Deniz On 03/24/2025 at 01:18 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: DELTA MEADOWS CARE HOME	FACILITY NUMBER: 480107184
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.69(a)(4)(G)

Other Provisions

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (4) The training shall cover all of the following areas: (G) An explanation of guidelines for the proper storage, security, and documentation of centrally stored medications. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in 4 count out of 4 total count centrally stored medication records weren’t recorded and documented per regulation which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/03/2025
	Plan of Correction
1 2 3 4	Licensee agrees to start using centrally stored medication records form for every medication given to clients by doctor. Administrator will submit MAR log and will provide self-certification for centrally stored medication training by plan of correction date(POC) on 04/03/2025.

Section Cited


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

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:

Victoria Bertozzi

LICENSING EVALUATOR NAME:

Ali Deniz

LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: DELTA MEADOWS CARE HOME	FACILITY NUMBER: 480107184
	VISIT DATE: 03/24/2025

NARRATIVE

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Continued from LIC809.

At approximately 10:40AM, LPA/Administrator reviewed 4 of 4 resident records and all found to be current. 4 of 4 records contained current and signed admission agreements and physician's orders on file. Medication was centrally stored and locked in the dining area. However, centrally stored medication records weren’t recorded and documented per regulation. The facility didn’t have any medication log records for any medication present at the facility (See LIC809-D page).

At approximately 12:05 PM, LPA reviewed the facility emergency disaster plan. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 02/21/2025.

Administrator Certificate is for Cecilia Ganzon #7034418740 expires 07/28/2026.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
Copy of Updated Certificate of Liability Insurance

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Ali Deniz
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025

LIC809 (FAS) - (06/04)

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