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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603579
Report Date: 10/29/2024
Date Signed: 10/29/2024 03:41:44 PM

Document Has Been Signed on 10/29/2024 03:41 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 CAREFACILITY NUMBER:
198603579
ADMINISTRATOR/
DIRECTOR:		MAXIMO, ROSAMARIAFACILITY TYPE:
740
ADDRESS:2433 ANGELA STREETTELEPHONE:
(626) 912-3415
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 4CENSUS: 4DATE:
10/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:29 PM
MET WITH:Danielle Maximo, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 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
Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. The purpose of the visit was explained to staff Jeffrey Sandejas. 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: The facility has a Dementia plan and hospice waiver for four (4) residents. A fire clearance for four (4) [3 non-ambulatory & 1 bedridden] residents age 60 and above, of which 1 resident may be bedridden in room #1. Facility handles resident P & I monies. The Surety Bond expires 2/8/2025. 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. Cleaning supplies, knives, and toxic substances were observed unlocked/accessible to residents above the washer/laundry area.

Two (2) broken chairs and a dresser were observed in the patio area. The side yard has a discarded shelf rack. Citation was issued.

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

Personnel Records/Staff Training: Administrator certificate expired 7/10/2024. Proof of pending approval from CCL Recertification Unit was provided. Staff have criminal background clearance and training. Four (4) staff files were reviewed. Proof of staff training, health and TB clearance, and 1st Aid/CPR training are on file.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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 3
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
FACILITY NUMBER: 198603579
VISIT DATE: 10/29/2024
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
26
27
28
29
30
31
32
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. The facility maintains centrally stored medication records.

RCFE complaint poster and Personal rights were observed posted.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. The facility has 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. Two (2) residents have a modified diet plan.

Incident Medical and Dental: Centrally stored resident medications were reviewed, which contained a 30-day supply of medications. Medical and dental transportation is provided by facility staff.

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 9/13/2024.

Residents with Special Health Needs: No residents are receiving hospice services or home health services. One (1) resident 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: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/29/2024 03:41 PM - It Cannot Be Edited


Created By: Noemi Galarza On 10/29/2024 at 03:23 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
FACILITY NUMBER: 198603579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024

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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that the exterior side yard had discarded furniture obstructing the side yard corridor. Photos taken. In addition, the appliances and kitchen cabinets were observed to be dirty, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2024
Plan of Correction
1
2
3
4
Licensee/Administrator shall remove all discarded furniture from the patio area and side yard. Submit picture proof that the items were removed.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3