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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603587
Report Date: 11/09/2023
Date Signed: 11/09/2023 03:36:37 PM

Document Has Been Signed on 11/09/2023 03:36 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 IIFACILITY NUMBER:
198603587
ADMINISTRATOR:ROSAMARIA MAXIMOFACILITY TYPE:
740
ADDRESS:2404 ANGELA STTELEPHONE:
(626) 839-4857
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 4CENSUS: 4DATE:
11/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:36 PM
MET WITH:Danielle Maximo, Assistant AdministratorTIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Administrator Rosamaria Maximo. Assistant Administrator Danielle Maximo arrived later. There are four (4) level 4C developmentally disabled adults over the age of 59. The facility is vendored by San Gabriel/Pomona Regional Center. A fire clearance for 4 non-ambulatory adults is in place.

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. Visitors are no longer being screened for COVID-19. The facility has an Infection Control Plan.


Operational Requirements:
  • The facility has a Dementia plan and hospice waiver for four (4) residents.
  • Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 6/20/2024.
  • Facility handles resident's money. A Surety Bond in the amount of $2,000 is in place.

Physical Plant/Environment Safety:
  • The facility is a single story home located in a residential neighborhood. The facility is staff operated and consists of 4 private resident bedrooms, 2 bathrooms, living room, dining room, kitchen, outdoor patio area and laundry area in 2-car attached garage.
  • 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. Kitchen drawers containing knives/sharp objects were locked.
  • The facility has one (1) fully charged fire extinguisher, fire pull alarm, and operable carbon monoxide and smoke detectors.
  • Water temperature readings did not measure within the required 105 - 120 degrees Fahrenheit. Citation was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: DELTA HOME CARE II
FACILITY NUMBER: 198603587
VISIT DATE: 11/09/2023
NARRATIVE
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Staffing:
  • A total of 10 caregiver staff provide care and supervision to the clients.

Resident Records/Incident Reports:
  • A total of four (4) resident files were reviewed. Files contained admission agreements, Physician's Reports, Appraisals, TB clearance, COVID-19 vaccine cards, Functional Capability Assessment, and emergency information.
  • RCFE complaint poster and Personal rights were observed posted in the facility.

Planned Activities:
  • Sufficient space to accommodate both indoor and outdoor activities was observed.
  • Indoor and outdoor activities are performed twice a week.
  • 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.
  • Physician orders for modified diets are in place.

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



See next page.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
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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 II
FACILITY NUMBER: 198603587
VISIT DATE: 11/09/2023
NARRATIVE
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Disaster Preparedness:
  • Emergency and Disaster Plan LIC 610E is in place.
  • The last emergency disaster drill was conducted on 10/14/2023.

  • Residents with Special Health Needs:
  • No residents are receiving home health services or enrolled in hospice care.
  • Postural support physician orders are on file.
  • No bed rails for mobility assistance were observed in resident beds.
  • Individual Service Plans and Appraisals were observed in resident files.
  • No residents have prohibited health conditions.


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 were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/09/2023 03:36 PM - It Cannot Be Edited


Created By: Noemi Galarza On 11/09/2023 at 02:31 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 II
FACILITY NUMBER: 198603587

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation. Water supplies and plumbing fixtures shall be maintained as follows: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the hot water temperature readings were 136.4 and 137.6 in bathrooms and 133.6 in the kitchen, which poses an immediate health and safety risk to persons in care.
POC Due Date: 11/10/2023
Plan of Correction
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Administrator shall ensure the hot water temperature in the facility is within 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). Submit a water temperature log showing hot water readings tested 3 times today and 3 times tomorrow 11/10/23.
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: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023


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Document Has Been Signed on 11/09/2023 03:36 PM - It Cannot Be Edited


Created By: Noemi Galarza On 11/09/2023 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 II
FACILITY NUMBER: 198603587

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
PERSONNEL REQUIREMENTS - GENERAL
All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that staff (S1) did not have current 1st Aid/CPR training on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2023
Plan of Correction
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Submit a copy of S1's 1st Aid/CPR training card.
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: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023


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