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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603587
Report Date: 12/03/2024
Date Signed: 12/03/2024 12:53:50 PM

Document Has Been Signed on 12/03/2024 12:53 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/
DIRECTOR:		ROSAMARIA MAXIMOFACILITY TYPE:
740
ADDRESS:2404 ANGELA STTELEPHONE:
(626) 839-4857
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 4CENSUS: 4DATE:
12/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Danielle Maximo, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:55 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 Ricardo Evangelista. Assistant Administrator Danielle Maximo arrived shortly after. The facility is licensed as an RCFE (Residential Care For the Elderly) for four (4) non-ambulatory developmentally disabled adults ages 60 and over. 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 fire clearance for 4 non-ambulatory residents ages 60 and over was approved on 6/2/2022. Facility handles resident P & I monies and has a current Surety Bond that expires 4/22/2026.

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 and a fire pull alarm in the living room. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. The facility has a 1st Aid Kit and Manual. Cleaning supplies, knives, and toxic substances were observed locked and inaccessible to residents.

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. Five (5) staff files were reviewed. Proof of staff training, health and TB clearance, and 1st Aid/CPR training are on file. Proof of in-service training that includes HCBS Final rule was observed in staff files.

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

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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 II
FACILITY NUMBER: 198603587
VISIT DATE: 12/03/2024
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. Centrally stored medication records are in place. Residents (R1- R4's) medical assessment forms were signed by MD, but not completely filled out. A citation was issued. Resident records included updates that fulfill Home and Community-Based Services (HCBS) Federal Requirements.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Daily activities and weekly calendar of activities was reviewed. 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. One (1) resident has a modified diet plan.

Incident Medical and Dental: Centrally stored resident medications were reviewed; containing 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 10/3/2024..

Residents with Special Health Needs: No residents are receiving hospice services or home health services. There are no residents have a restricted health care plan.

A deficiency was cited.



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

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/03/2024 12:53 PM - It Cannot Be Edited


Created By: Noemi Galarza On 12/03/2024 at 12:27 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: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that residents (R1- R4's) medical assessment forms were signed by MD, but forms were not filled out completely, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
1
2
3
4
Administrator shall submit a copy of R1-R4's medical assessments.
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: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


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