Delia's Residential Community 3

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management for annual continuation from 3/26/2026. LPA Rai met with Administrator, Carmen Buno and stated the purpose of today's visit. LPA Rai reviewed at random 2 staff files and 2 resident files. 2 Out of 2 staff files were complete. 2 Out of 2 resident files were complete. LPA Rai reviewed at random 2 medications and medication records. LPA Rai observed resident R1's 2 out of 8 medications did not have start date on the Centrally Stored Medication Log. LPA Rai observed R1's 1 out of 8 medications (MED1) which were centrally stored not recorded on the Centrally Stored Medication Log. LPA Rai and facility staff S1 counted the tablets remaining in MED1 were 39 tablets when the initial tablets in the medication when filled was 100 tablets. S1 stated the facility staff are administering MED1 to resident R1 1 tablet daily. LPA Rai observed 2 out of 8 medications (MED2 & MED3) did not have start dates written on the Centrally Stored Medication Log. LPA Rai and S1 counted tablets remaining in MED2 bottle which was 46 tablets, when originally it was filled with 100 tablets. LPA Rai and S2 counted tablets remaining in MED3 bottle which was 26 tablets, when originally it was filled with 90 tablets. S1 stated the facility staff are administering MED2 and MED3 to resident R2 1 tablet daily. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Continuation on LIC 809-C, Page 1 of 2. Page 2 of 2. 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, Apr 7, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6) · Plan of correction due date: Apr 14, 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 R1's 1 out of 8 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, Apr 7, 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.

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 and 4 residents at 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 1 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, living room, dining room and kitchen. 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 111.7 - 114.4 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 03/09/2026. LPA Rai observed a complete first aid kit at the facility. This annual inspection will be completed at a later date. This report was reviewed with Administrator, Carmen Buno and a copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 26, 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, 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 5 residents at 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 1 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, 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 113.8 - 114.6 degrees F. Fire extinguisher was observed and inspected on 01/21/2025. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drill was conducted on 01/09/2025. LPA Rai observed a complete first aid kit at the facility. LPA Rai reviewed facility records for 2 staff and 2 residents. LPA Rai reviewed resident medications and central stored medication records. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Dina Domingo & Carmen Buno and a copy of the report was provided. LIC 858 and LIC 859 were provided.the state’s words, verbatim · CDSS document, Mar 27, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Designated Administrator (DA) Carmen Buno. LPA Rai observed 1 staff (S1) and 3 residents at the facility since 1 resident was out of the facility. At approximately 9:20am, LPA rang the doorbell and no one answered the door. At approximately 9:35am, the resident (R3) opened the door and stated there was no staff in the home and to wait for someone to come. At approximately 9:30am, staff (S1) opened the door and let LPA enter the facility. S1 stated the employee was newly hired and assisted residents with activities of daily living (ADLs) as a caregiver. S1 stated S1 was not fingerprinted and planned to go today 3/8/2024 to submit the application. Per interview with DA, S1 assisted DA with the residents and DA is aware S1 is not Criminal Background Cleared and DA understands staff who work with residents need to be Criminal Background Cleared before they start to work at the facilty. During visit, LPA Rai toured the inside and outside of the facility with staff (S2). When touring the outside area of the facility, the exits were cleared of obstruction. 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 a closet next to the front door which was unlocked and contained food supply and cleaning supplies. DA and S2 removed the cleaning supply items to the laundry room. LPA observed the cleaning supply and the laundry detergents located in the cabinets in the laundry room accessible to resident in care. LPA observed laundry detergent under the utility sink next to the laundry machine. At the time of visit, laundry machine was not in use. Continuation on LIC 802-C, Page 1 out of 3. Page 2 of 3. LPA Rai toured the resident bedrooms. 5 out of 5 resident bedrooms had available bedding, drawers, and functioning lights. LPA observed 2 out of 4 resident bed had half-side rails and residents were not under Hospice services. DA 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. LPA Rai observed prescription medication and over the counter (OTC) medication in 2 out of the 5 residents rooms. DA stated she was not aware of the medications in the resident's room. S2 stated R1 administered the medication themselves and the staff administer the medications for R2 but keep the medications in R2's room. LPA observed R2 medications accessible to residents in care. The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 115.5 degrees F - 117.1 degrees F. The water temperature in the kitchen sink was 116.5 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 DA and S2, 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. LPA Rai reviewed facility records for 2 staff and 2 residents. 2 out of 2 staff files contained documents from when the building was licensed under a different license. DA stated the facility hired some of the staff from the previous license when the Department approved their license. DA 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. Page 3 of 3. R3's resident files did not contain Needs and Services Plan and R3 has a diagnosis of Dementia. R4's resident files did not contain a complete Needs and Services Plan dated 11/8/2022 which is not signed. R4's resident file did not contain LIC 613 Personal Rights. DA reviewed LIC 613 Personal Rights with R4 in his/her room during today's visit. LPA Rai reviewed resident medications and central stored medication records. A civil penalty is being assessed for the amount of $400 ($100 per day x 4 days = $500), for staff (S1) working at the facility without a Criminal Background clearance transfer. Please see LIC 421BG. Per DA, S1 worked at the facility on February 26, February 27, February 28th and March 8th 2024. Deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Designated Administrator (DA) Carmen Buno and a copy of the report was provided. Technical Violation and Technical Assistance was provided. Appeal Rights were provided.the state’s words, verbatim · CDSS document, Mar 8, 2024

The state marks this report as 16 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.