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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603577
Report Date: 10/14/2024
Date Signed: 10/14/2024 04:28:49 PM

Document Has Been Signed on 10/14/2024 04:28 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:DELTA HOME CARE IIIFACILITY NUMBER:
198603577
ADMINISTRATOR/
DIRECTOR:		ROSAMARIA MAXIMOFACILITY TYPE:
740
ADDRESS:2400 ANGELA ST.TELEPHONE:
(626) 912-3454
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 4CENSUS: 4DATE:
10/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:03 PM
MET WITH:Daniell Maximo, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. The purpose of the visit was explained to DSP Elmer Santos. Assistant Administrator Danielle Maximo arrived shortly after. The facility is licensed for 4 elderly developmentally disabled residents 60 years and older. The facility is licensed as a level 4C RCFE vendored by San Gabriel/Pomona Regional Center. The following 12 Care Compliance and Regulatory Enforcement (CARE) tool domains were utilized during the inspection.

The following were observed/inspected:



Infection Control: The Infection Control Plan was reviewed. The facility has a supply of Personal Protective Equipment (PPEs).

Operational Requirements: A hospice waiver for 4 and Dementia waiver is in place. A fire clearance for 4 non-ambulatory residents age 60 and above, of which 1 resident may be bedridden in room #4. Facility handles resident P & I monies and has a current Surety Bond (8/15/2025). Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 6/20/2025.

Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. The facility has one (1) fully charged fire extinguisher. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Facility has a fire pull-alarm in the dining area and heat detectors.

Cleaning supplies, knives, and toxic substances were observed unlocked/accessible to residents above the washer/laundry area. Discarded furniture was observed outside the north side of the home, and bathroom #2 had mold on tile and shower mat.

Staffing: A total of 8 staff members provide care and supervision to the clients.

Personnel Records/Staff Training: Administrator certificate expired 7/10/2024; pending approval from CCL Recertification Unit. Staff have criminal background clearance and training. Five (5) staff files were reviewed. Proof of staff training, health and TB clearance, and 1st Aid/CPR training are on file.

****Report narrative continues next page.*****

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: DELTA HOME CARE III
FACILITY NUMBER: 198603577
VISIT DATE: 10/14/2024
NARRATIVE
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Resident Records/Incident Reports: Four (4) resident files were reviewed. They contained admission agreements, IPPs, Behavior Plans, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent. Centrally stored medication records are in place.

RCFE complaint poster and Personal rights were observed posted.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. The facility does not have a Resident Council.

Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. One resident has a modified diet plan.

Incident Medical and Dental: Four (4) centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided by facility staff.

An error on resident (R1's) Medication Administration Record was observed. It stated that medication Levothryroxine 50 MCG is to be administered at 5 PM, but it should be medication Levetiracetam 500 mg. Staff are putting their initials on the wrong medication line. A citation was issued.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual. The last emergency disaster drill was conducted on 10/5/2024.

Residents with Special Health Needs: No residents are receiving hospice services or home health services. Resident (R1) has a restricted health care plan on file.

Per California Code of Regulations, Title 22, deficiencies were cited.



Exit interview was conducted with Assistant Administrator Danielle Maximo. A copy of the report and appeal rights was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
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Page: 2 of 4
Document Has Been Signed on 10/14/2024 04:28 PM - It Cannot Be Edited


Created By: Noemi Galarza On 10/14/2024 at 03:40 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DELTA HOME CARE III
FACILITY NUMBER: 198603577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section above in that Knives, bleach, and detergents were unlocked in the cabinet above the washer & dryer,] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2024
Plan of Correction
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Staff immediately locked the cabinet.
Administrator shall conduct staff training regarding regulation 87309, and submit staff training log by tomorrow.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/14/2024 04:28 PM - It Cannot Be Edited


Created By: Noemi Galarza On 10/14/2024 at 03:40 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DELTA HOME CARE III
FACILITY NUMBER: 198603577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that bathroom #2 had mold on non-slip shower mat & tile, and there was discarded furniture [dresser, walker, wood planks] on the side of the property, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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Administrator shall submit:
1. Picture proof that bathroom #2's tile was cleaned, is free of mold, and a shower mat has been replaced.
2. Picture of the side yard showing the discarded furniture has been removed.
Type B
Section Cited
CCR
87411(d)(4)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them.... (4) Knowledge required to safely assist with prescribed medications which are self-administered.
This requirement was not met evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that staff did not do their due diligence in reviewing all medication records and physician orders; R1’s MAR had errors that did not match the bubble pack medication orders instructions, which poses a potential health and safety risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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Submit proof that all staff were trained in regulation 87411(d)(4), and 87465. Submit a copy of the correct MAR record for R1.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2024


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