Delia's Residential Community 1

Type of visit: POC

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to clear the deficiencies issued during today's visit. LPA Rai met with the Administrator, Carmen Buno and stated the purpose of today’s visit. During today's visit, LPA Rai cleared deficiencies issued during visit conducted on 03/26/2026. During today's visit, LPA observed the Centrally Stored Medication log was completed and Appraisal/Needs and Services Plan was completed and signed by residents and/or resident's responsible party, Theft & Loss Policy and the sections 1569.152 and 1569.154 was signed by residents and/or resident' responsible party. LPA Rai observed staff files to have completed and signed documents which include the SOC 341A and complete Health Screening Report. LPA Rai observed In-service Training Sign In Sheet for 4/5/2026 for the following topics: Medication Management: logging medication to Centrally Stored Medication Log, Physician's Orders and Medication Administration Record and LPA Rai observed signatures of 7 staff present during the in-service. LPA Rai provided Licensee Letter of Deficiency Citations Cleared for deficiencies issued during today's visit. Exit interview conducted with Administrator, Carmen Buno and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 7, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Administrator, Carmen Buno and stated the purpose of today's visit. LPA Rai observed 2 staff 4 residents at the facility as 1 resident is out of the facility. During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai observed 2 shed in the backyard which was locked and used for storage and not habitual space. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. LPA Rai toured the facility to include 6 resident rooms, 1 staff room, living room, dining room, kitchen and garage. 6 Out of 6 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. The hot water temperature in the bathroom and kitchen sink ranged from 115.5 - 118.2 degrees F. Fire extinguisher was observed and inspected on 01/07/2026. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drills were conducted on 12/20/2025 and 03/10/2026. LPA Rai observed a complete first aid kit at the facility. Continuation on LIC 809-C, Page 1 of 2. Page 2 of 2. LPA Rai reviewed facility records for 2 residents. During review of R1's facility records, R1's Appraisal/Needs and Services Plan dTED 04/2025 and Theft& Loss Policy was not signed by resident or resident's responsible party. LPA Rai reviewed facility records for 2 staff. During review of S1's facility records, S1 did not have an signed SOC 341A Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders and Health Screening Record was not on file. LPA Rai reviewed resident medications and central stored medication records. During review of resident R2's medications, 1 out of 6 medications (MED1) was not recorded on Centrally Stored Medication Records and R2 has signed physician's orders for MED1 and ADM stated staff are currently administering the medication to R2. A civil penalty is being assessed for the amount of $250 for repeat violation for CCR 87465(h)(6) for licensee did not assure that a record of centrally stored prescription medications for each resident is maintained for at least one year wherein resident R1's medication was not recorded on the Centrally Stored Medication Log. See LIC421FC. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. This report was reviewed with Administrator, Carmen Buno and a copy of the report was provided. LIC 858 and LIC 859 were provided. Appeal Rights was provided.the state’s words, verbatim · CDSS document, Mar 26, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6) · Plan of correction due date: Apr 2, 2026

87465 Incidental Medical and Dental Care (h) (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year... This requirement is not met as evidenced by: Based on interview and record review, resident R2's 1 out of 6 medications was not logged on the Centrally Stored Medication Log which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 26, 2026

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure R1's centrally stored prescription medication are recorded on the Centrally Stored Medication log by POC due date. Administrator agreed and understood.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87457(c)(3) · Plan of correction due date: Apr 2, 2026

87457 Pre-Admission Appraisal (c)(3) The prospective resident, or his/her responsible person, if any, shall be involved in the development of the appraisal. This requirement was not met as evidenced by: Based on review of resident records, resident R1's Appraisal/ Needs and Services Plan dated 04/2025 was created but it was not signed by the resident or his/her responsible party which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 26, 2026

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure resident's Appraisal/Needs and Services Plan is signed by resident or his/her responsible person by POC due date. Administrator agreed and understood.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.153(k) · Plan of correction due date: Apr 2, 2026

§1569.153 (k) A copy of this section and Sections 1569.152 and 1569.154 is provided by a facility to all of the residents and their responsible parties, and... to all of the facility's prospective residents and their responsible parties. This requirement was not met as evidenced by: Based on review of resident R1's file, R1 did not have a signed document stated they received the Theft & Loss Policy and the sections 1569.152 and 1569.154 was provided to the resident and/or resident's responsible party which poses/posed a potential health, safety orthe state’s words, verbatim · CDSS document, Mar 26, 2026

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure Theft & Loss Policy and the sections 1569.152 and 1569.154 was provided to the resident and/or resident's responsible party by POC due date. Administrator agreed and understood. (con't) personal rights risk to persons in care.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(c) · Plan of correction due date: Apr 2, 2026

87211 (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours... This requirement was not met as evidenced by: Based on review of staff S1's file, S1 did not have a signed SOC341A statement acknowledging requirement to report suspected abuse of dependent adult and elders which poses/posed a potential health, safety or personal rights risk to personsthe state’s words, verbatim · CDSS document, Mar 26, 2026

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure staff files contain a signed SOC341A by POC due date. Administrator agreed and understood. (con't) in care.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(f) · Plan of correction due date: Apr 2, 2026

87411 Personnel Requirements - General All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. This requirement is not met as evidenced by: Based on review of S1's file, S1 did not have a Health Screening Report on file which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 26, 2026

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure staff file has Health Screening Report by POC due date. Administrator agreed and understood.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit follow up on the Type A & Type B deficiencies cited on 3/27/2025. LPA Rai met with Administrator (ADM) Dina Domingo and stated the purpose of today's visit. LPA reviewed the Plan of Correction submitted on 3/28/2025 and 4/3/2025. LPA Rai reviewed resident R1's updated Admission Agreement and R1's Centrally Stored Medication Record. During today's visit, LPA Rai observed resident's room and the exit door was free from obstruction. LPA Rai observed the wooden block was removed from the door and a door alarm was placed. ADM stated they have placed a door alarm on the sliding door. During visit, LPA provided letter of the Deficiency Citations cleared. No deficiencies were cited at this time as per California Code of Regulations, Title 22. This report was reviewed with Administrator, Dina Domingo and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 9, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Administrator, Dina Domingo & Carmen Buno and stated the purpose of today's visit. LPA Rai observed 2 staff who have obtained a Criminal Record Clearance. LPA Rai observed 2 residents at the facility, 1 resident at the day program and 1 resident at the hospital. During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai observed 2 sheds in the backyard which was locked and used for storage and not habitual space. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. LPA Rai toured the facility to include 6 resident rooms, 1 staff room, living room, dining room, kitchen and garage. 6 Out of 6 resident bedrooms had available bedding, drawers, and functioning lights. LPA Rai observed resident R1's room and exit door located in the room. Administrator (ADM) Dina Domingo removed a pole from the top of the screen door which restricted resident from using the exit door. ADM stated R1 exhibited exit seeking behaviors. LPA Rai observed a working door alarm on the exit and the door had locking capabilities. LPA Rai observe safety covers on 2 exit door knobs which hindered the residents from opening the door. ADM removed the child safety covers on the doors. Continuation on LIC 809-C, Page 1 of 2. Page 2 of 2. The facility bathroom had available soap, paper towels, and trash cans with lids. The hot water temperature in the bathroom and kitchen sink ranged from 117.6 - 118.1 degrees F. Fire extinguisher was observed and inspected on 01/21/2025. Facility smoke detectors and carbon monoxide detectors were in working condition. Facility staff had disaster drills conducted on 01/03/2025 & 01/08/2025. LPA Rai observed a complete first aid kit at the facility. LPA Rai reviewed facility records for 2 staff and 2 residents. LPA Rai observed 1 out of 2 admission agreements were not signed by resident and/or resident's responsible party. LPA Rai reviewed resident medications and central stored medication records. LPA Rai observed resident R1's 4 out of 7 medications were not recorded on the Centrally Stored Medication Log. Per Staff S1, R1 has been administered the medication and LPA Rai observed tablets were taken from the bottle. Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. This report was reviewed with Administrator, Dina Domingo and a copy of the report was provided. LIC 858 and LIC 859 were provided. Appeal Rights were provided.the state’s words, verbatim · CDSS document, Mar 27, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(d)(6) · Plan of correction due date: Mar 28, 2025

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not ensure that sliding exit doors tracks were free of obstruction. LPA observed a wooden block obstructing the sliding exit door tracks which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: During visit, Administrator removed the objects (a wooden block) from the sliding exit doors track. Administrator stated to submit a written plan to ensure all indoor and outdoor passageways and stairways are free from obstruction via email by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(a) · Plan of correction due date: Apr 3, 2025

87507 Admission Agreements (a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. This requirement is not met as evidenced by: Based on interview and record review, 1 out of 2 resident files did not contain Admission Agreement which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure R1's Admission Agreement is signed by POC due date. Administrator agreed and understood.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(h)(6) · Plan of correction due date: Apr 3, 2025

87465 Incidental Medical and Dental Care (h) (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year... This requirement is not met as evidenced by: Based on interview and record review, 4 out of 7 medications were not logged on the Centrally Stored Medication Log which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure R1's centrally stored prescription medication are recorded on the Centrally Stored Medication log by POC due date. Administrator agreed and understood.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Carmen Buno. LPA Rai observed 2 staff and 5 residents at the facility during visit. During visit, LPA Rai toured the inside and outside of the facility with staff (S1). When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai observed 2 shed and they were used for storage and not habitual space. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA Rai toured the resident bedrooms. 6 out of 6 resident bedrooms had available bedding, drawers, and functioning lights. LPA observed 6 out of 6 resident bed had half-side rails and 2 residents were under Hospice services. ADM stated the residents do not have doctor's orders for the residents to use half-side rails and was not aware resident's need physician's order for bedrails. LPA reviewed resident's Admission Agreement and on page 22, the facility stated the procedure of obtaining physician's order for bedrails. The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sink was 117.8 degrees F. The water temperature in the kitchen sink was 114.8 degrees F. The temperature of the facility was measured at 72 degrees F on the thermostat. Fire extinguisher was observed and inspected on 02/04/2024. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drill was conducted on 10/4/2023. Per ADM and S1, Administrator conducted a disaster drill in January 2024 but could not locate the document. LPA Rai observed an Emergency and Disaster Plan binder which located all drill records for the past 2 years. Continuation on LIC 809-C, Page 1 of 2. Page 2 of 2. LPA Rai reviewed facility records for 2 staff. 2 out of 2 staff files contained documents from when the building was licensed under a different license. ADM stated the facility hired some of the staff from the previous license when the Department approved their license. ADM stated they retained the old documents and placed them in the file. LPA Rai stated the facilty needs retain documents that are issued from the current Licensee and the previous documentation may not be appropriate. LPA Rai is working with the Licensee since the staff are shared between different facilities. LPA Rai reviewed facility records for 2 residents. 2 out 2 resident files did not contain Consent Form and Personal Rights. LPA Rai reviewed resident medications and central stored medication records for 2 residents. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator (ADM) Carmen Buno and a copy of the report was provided. Technical Violation and Technical Assistance was provided.the state’s words, verbatim · CDSS document, Mar 14, 2024