198603587-10-7-2025-28-AS-NGAA-DM8UQ5-20251007154636

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603587
Report Date: 10/07/2025
Date Signed: 10/07/2025 03:46:49 PM

Document Has Been Signed on 10/07/2025 03:46 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 II		FACILITY NUMBER:	198603587
ADMINISTRATOR/ DIRECTOR:	ROSAMARIA MAXIMO		FACILITY TYPE:	740
ADDRESS:	2404 ANGELA ST		TELEPHONE:	(626) 839-4857
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91792
CAPACITY: 4		CENSUS: 2	DATE:	10/07/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:43 PM
MET WITH:	Danielle Maximo, Assistant Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:50 PM

NARRATIVE

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Licensing Program Analyst (LPA) Galarza conducted an unannounced annual inspection visit. The purpose of the visit was explained to Assistant Administrator Danielle Maximo. The facility serves elderly residents ages 60 and older whom are developmentally disabled. The facility is licensed as a level 4 RCFE vendored by San Gabriel/Pomona Regional Center.

The following were observed/inspected:

Infection Control: The Infection Control Plan was reviewed and includes environmental cleaning and disinfection activities. Facility has sufficient Personal Protective Equipment.

Operational Requirements: A hospice waiver for 4 residents is approved. A fire clearance was granted for 4 non-ambulatory residents. 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 6/20/2026. Facility handles resident P & I monies. The Surety bond expires 2/8/2028.

Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood consisting of 4 private resident bedrooms, 2 bathrooms, living room, dining room/kitchen, outdoor patio area with patio furniture, and 2 car detached garage with laundry area. Smoke and carbon monoxide detectors were tested and are operational. The facility has one (1) fire extinguisher. 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 are inaccessible to residents. The last Emergency Disaster drill was conducted on 10/4/2025.

Bedroom #3's mini blinds are in disrepair/torn and bedroom #2’s door that exits to the side yard has a gap on the left side of casing/door closure area.

Staffing: A total 6 staff members provide care and supervision to the clients.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 10/07/2025

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Personnel Records/Staff Training: Administrator certificate expires 7/20/2026. Staff have criminal background clearance and training. Six (6) staff files were reviewed. Proof of continuing education/staff training, health clearance, and 1st Aid/CPR training is current.

Resident Records/Incident Reports: Four (4) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent, and Medication Administration records. R1'R4's Physician Reports are incomplete.

RCFE and Ombudsman complaint posters are posted in the facility.

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

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 requires a modified diet.

Incident Medical and Dental: Centrally stored resident medications were reviewed. 30-day supply of medications was observed. 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.

Residents with Special Health Needs: No residents receive hospice care or home health services at this time. No residents have prohibited health conditions. Two (2) residents are currently at a higher level of care facility.

Pursuant to Title 22, deficiencies were cited.

An exit interview was conducted with Assistant Administrator Danielle Maximo. A copy of the report and appeal rights was issued.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/07/2025 03:46 PM - It Cannot Be Edited

Created By: Noemi Galarza On 10/07/2025 at 03:21 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: 10/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(c)(1)

Medical Assessment

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: 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) have Physician's Reports on file, but pages 2-5 are blank, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/04/2025
	Plan of Correction
1 2 3 4	Administrator shall submit copies of R1-R4's Physician's Reports completely filled out by MD.

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; bedroom #3's mini blinds are in disrepair/torn and bedroom #2’s door that exits to the side yard has a gap on the left side of casing/door closure area, which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/04/2025
	Plan of Correction
1 2 3 4	Administrator shall submit picture proof evidence of repaired mini blinds in room #3 and repairs made to room #2's door.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:

	Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/07/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

LIC809 (FAS) - (06/04)

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