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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480110447
Report Date: 04/21/2023
Date Signed: 04/24/2023 11:49:16 AM

Document Has Been Signed on 04/24/2023 11:49 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:DELGADO ADULT RESIDENTIAL HOMEFACILITY NUMBER:
480110447
ADMINISTRATOR:KAMAL RAIFACILITY TYPE:
735
ADDRESS:123 ZINNIA CIRCLETELEPHONE:
(707) 647-0941
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 3DATE:
04/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:21 PM
MET WITH:Mahindra RaiTIME COMPLETED:
02:07 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct an Annual Required 1 Year inspection and met with Licensee, Mahindra Rai.

LPA toured the inside and outside of this facility, which was found to be clean at a comfortable temperature and with all walkways and exits unobstructed. Client rooms were furnished per regulation. Water temperature accessible to clients in care measured 115 degrees F which are within the required regulation range of 105 to 120 degrees F.
Extra hygiene products and linens were available. Cleaning supplies are locked and not accessible to clients. Facility has more than two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked in medication cabinet.

Fire extinguishers were last serviced 1/31/2023. Smoke/Carbon Monoxide detectors were operational. Most recent fire/disaster drill was documented and conducted April 1, 2023.

Staff and Client files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate #6022342735 for Administrator, Kamal Rai expires 12/1/2024.

LPA also went over a recent incident report that was called in and submitted timely by the facility that involved client C1 being aggressive towards client C2.

Continued on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2023
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: DELGADO ADULT RESIDENTIAL HOME
FACILITY NUMBER: 480110447
VISIT DATE: 04/21/2023
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Continued from LIC809

Administrator and LPA discussed their Emergency Disaster Plan, Infection Control Plan and discussed the recent PIN that allows facilities to discontinue Covid-19 screening. Facility will update Infection Control plan of operation if there are changes they want to update.

Licensee/Administrator to submit updates of the following documents by 5/10/2023.



LIC 500 Personnel Summary
LIC9020 Register of clients
LIC400 and Copy of Surety Bond
Emergency Disaster Plan


No deficiencies cited during this inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
LIC809 (FAS) - (06/04)
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