Delphinium Manor

Type of visit: Required - 1 Year

At 8:40am on 06/29/2026, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to conduct the facility annual inspection. LPA met with facility Administrator, Hermi Gonzales, announced who he is and the reason for the visit. Administrator and LPA conducted a physical tour of facility, LPA noted that this is a seven bedroom, one full bath, three on-sute baths rooms (Rooms 2, 3, 4), kitchen, dining room, living room and activity room, and the laundry is located in the garage. There is a staff bedroom located near the front entrance. There is a large L-shaped back yard with seating and umbrellas for client activities and visitation. LPA noted that all residents rooms meet regulation standards in bedding, furniture, lighting and facility temperature. LPA noted that all rooms have exits to the backyard and have auditory devices on the doors which were tested and functioning. LPA noted that there is at least 2 days of perishable food and at least 7 days on non-perishable foods on hand for six residents and staff. LPA noted that the facility has emergency water stored in the garage area. LPA noted that the facility water temperature was tested throughout the facility to be in regulation standards of 105*(f)-120*(f). LPA noted that the facility was a comfortable temperature of 70*(f). LPA noted that all door ways, passage ways and exits were free and clear of debit. LPA noted that the fire extinguisher located near the front entrance was primed and in the green, indicating working. LPA noted that the carbon monoxide detector was tested and working, as well as hardwired and battery smoke detectors in each resident room. LPA noted that there is a full first aide kit located in a locked cabinet where the medications are locked and stored. LPA reviewed facility emergency disaster plan, infection control plan, liability insurance, plan of operations, resident and staff files including annual staff training. LPA also reviewed resident Centrally Stored Medication Records (CSMR) LPA noted no citations during the physical tour of the facility. Administrator and LPA conducted a full review of the annual care tools. LPA noted no citations during this annual inspection. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Jun 29, 2026

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 10:30AM. LPA met with Lead Caregiver Divina Bigay and explained the reason for the visit. Administrator Hermi Gonzalez arrived shortly thereafter. Entrance interview conducted. Beginning at 11:00AM, the LPA, along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: Fire extinguisher was fully charged with purchased date of 07/24/2024. Carbon monoxide and Hardwired smoke alarms were tested and all were functional at the time of the visit. LPA observed exit alarms by all doors which were functional at the time of the visit. KITCHEN: LPA inspected the kitchen. Knives are locked in a drawer and cleaning supplies are stored inaccessible in a locked cabinet under the sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of 2 (two) days perishable and 7 (seven) days non-perishable food. Food was stored at appropriate temperatures. BEDROOMS: There are 7 (seven) total bedrooms in the facility; 6 (six) are designated as private resident rooms and 1 (one) is designated as a staff room. All 6 (six) resident bedrooms have exits to the exterior. Bedrooms #2, #5, and #6 have private bathrooms. All resident rooms are appropriately furnished and lighting in the rooms appeared adequate. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. The bedrooms were large enough to allow for easy passage. Report Continued on LIC 809-C BATHROOMS: There are 4 (four) total bathrooms, of which 3 (three) are attached to resident rooms. Restrooms were observed to contain nonskid mats. Grab bars by the showers and toilets were observed in the bathrooms. The water temperature was measured in the common bathroom and measured at 114.3 degrees Fahrenheit, which is within the required range. LPA observed storage space closets in hallway containing clean linens for resident use. GARAGE: The LPA toured the locked garage. The garage has a washer and dryer, locked cleaning supplies, an additional refrigerator and freezer, an emergency water supply, and an additional pantry for extra food. COMMON AREAS: This includes the living room, dining room, and activity room areas. LPA observed common areas to be clean and properly furnished at the time of the visit. OUTDOOR SPACE: The backyard has covered patio areas with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. There were no bodies of water on the premises. LPA observed a locked storage shed in the backyard. LPA observed a latched self-closing side gate, as is required. RECORD REVIEW: LPA began record review at 11:30 a.m. The LPA observed documentation of Infection Control Plan, Emergency Disaster Plan and last emergency drill (conducted on 05/14/25). The LPA reviewed four (4) out of four (4) resident files and 3 (three) staff files for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. The following was observed: Resident 1 (R1) did not have a signed Physician's report on file, R1 was recently admitted, went to a doctor's appointment today and will obtain their physician report. R2 needs and service plan is overdue by a month, and R3 had a negative TB checked off on their LIC602, with note "ask them for documentation, and was told it was negative. Otherwise All resident and staff files were complete and had no missing documents. MEDICATION REVIEW: Medications for 2 (two) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit. The first aid kit was complete. INTERVIEWS: During today's visit, LPA interviewed two (2) staff and one (1) resident. No immediate concerns were voiced. During today's visit, LPA obtained a copy of the facility's liability insurance, staff and resident rosters. No deficiencies were cited. Exit interview conducted and report provided.the state’s words, verbatim · CDSS document, Jun 6, 2025

The state marks this report as 8 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 9:28AM. LPA met with Lead Caregiver Divina Bigay and Licensee/Administrator Hermi Gonzalez who arrived at 10:10AM. Entrance interview conducted. Beginning at 9:30AM, the LPA, along with the Lead Caregiver toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: Fire extinguisher was not fully charged with it last being serviced on 12/14/2022. Administrator purchased and installed a new fire extinguisher during the time of the visit. Hardwired combination smoke and carbon monoxide detectors were tested at 10:56AM and all were functional at the time of the visit. LPA observed exit alarms by all doors which were functional at the time of the visit. KITCHEN: LPA inspected the kitchen at 9:33 AM. Knives are locked in a drawer and cleaning supplies are stored inaccessible in a locked cabinet under the sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of 2 (two) days perishable and 7 (seven) days non-perishable food. Food was stored at appropriate temperatures. BEDROOMS: There are 7 (seven) total bedrooms in the facility; 6 (six) are designated as private resident rooms and 1 (one) is designated as a staff room. All 6 (six) resident bedrooms have exits to the exterior. Bedrooms #2, #5, and #6 have private bathrooms. All resident rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linens; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage. Report Continued on LIC 809-C BATHROOMS: There are 4 (four) total bathrooms, of which 3 (three) are attached to resident rooms. Restrooms were observed to contain nonskid mats. Grab bars by the showers and toilets were observed in the bathrooms. The water temperature was measured in all 4 (four) bathrooms and measured between 105.3 and 113.2 degrees Fahrenheit, which is within the required range. LPA observed storage space closets in hallway containing clean linens for resident use. GARAGE: At 9:52AM, LPA toured the locked garage. The garage has a washer and dryer, locked cleaning supplies, an additional refrigerator and freezer, an emergency water supply, and an additional pantry for extra food. COMMON AREAS: This includes the living room, dining room, and activity room areas. LPA observed common areas to be clean and properly furnished at the time of the visit. OUTDOOR SPACE: The backyard has covered patio areas with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. There were no bodies of water on the premises. LPA observed a locked storage shed in the backyard. LPA observed a latched self-closing side gate, as is required. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 05/10/2024. RECORD REVIEW: LPA began record review at 10:05AM. LPA reviewed 5 (five) out of 5 (five) resident files and 3 (three) staff files for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. All resident and staff files were complete and had no missing documents. MEDICATION REVIEW: Medications for 2 (two) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit. The first aid kit was complete. Report Continued on LIC 809-C INTERVIEWS: During today's visit, LPAs interviewed 2 (two) staff and 2 (two) residents. During today's visit, LPA obtained a copy of the facility's liability insurance. Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiency may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 24, 2024

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.