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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603579
Report Date: 09/25/2026
Date Signed: 09/25/2026 02:48:11 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/25/2026 02:48 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 CAREFACILITY NUMBER:
198603579
ADMINISTRATOR/
DIRECTOR:		MAXIMO, ROSAMARIAFACILITY TYPE:
740
ADDRESS:2433 ANGELA STREETTELEPHONE:
(626) 912-3415
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 4CENSUS: 4DATE:
09/25/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Maximo DanielleTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced annual inspection visit. LPA met with Assistant Administrator Maximo Danielle who assisted with the visit. LPA explained the reason for the visit. The facility is licensed for non ambulatory residents age range 60 and over. The facility vendorized as a level 4 RCFE by San Gabriel/Pomona Regional Center. The facility has a Dementia plan and hospice waiver for four (4) residents which one can be bedridden.

The facility is a single story structure located in a residential neighborhood. It consists of the following: (5) resident bedrooms, (2) resident bathroom, kitchen, living room, dinning area. Laundry are observed in the attached garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the backyard. LPA toured the facility. All indoor and outdoor passageways were free of obstruction. The kitchen was inspected. LPA observed a layer of grease and debris accumulated on and around the kitchen gas stove and kitchen cabinets. Also observed that kitchen cabinet drawer was loose and unstable. LPA observed sufficient supply of perishable and non-perishable foods. Sharps, cleaning supplies are locked in the kitchen and in the garage and inaccessible to residents. Smoke / Carbon monoxide detectors observed in the common areas and in the residents rooms. There is (1) fire extinguisher located in the dining area which is fully charged. The common areas were properly furnished. Residents rooms were toured. All rooms had the required furniture and furnishings. LPA observed dust and debris accumulated along windows and sliding door tracks throughout the facility, including in residents rooms. Medications are centrally stored in a locked cabinet in the kitchen and inaccessible to residents. The resident bathrooms are clean and operational w/grab bars and non-skid surface/mats in place. The hot water temperature was tested and maintained within the required range of 105-120*F. The first aid kit was observed and found to be in compliance with the Title 22 Regulations.

Continue 809C

Wei Siew Ho
Nune Margaryan
DATE: 09/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2026
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
FACILITY NUMBER: 198603579
VISIT DATE: 09/25/2026
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The first aid kit was observed and found to be in compliance with the Title 22 Regulations. LPA reviewed client's and staff files. All files are updated. LPA confirmed staff working have fingerprint clearances. LPA reviewed clients medications. Medications are documented properly and given as prescribed. Fire drill was conducted on 08/15/2026.

Deficiency has been noted on LIC 809D under Title 22 Regulations.

Exit interview conducted with Assistant Administrator and a copy of this report and appeal right were provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/25/2026 02:48 PM - It Cannot Be Edited


Created By: Nune Margaryan On 09/25/2026 at 02:10 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
FACILITY NUMBER: 198603579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/09/2026
Section Cited
CCR
87303(a)

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Maintenance and Operation. (a)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 not met as evidenced by:
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Licensee / Administrator will thoroughly clean and remove grease, dust, and debris from all affected areas for the facility. Licensee / Administrator will also repair or replace the loose and unstable drawer in the kitchen. Submit proof of corrections to CCL by POC due date.
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Based on observation, the Licensee/ Administrator did not ensure that the facility was maintained clean, sanitary and in good repair. LPA observed a layer of grease and debris accumulated on and around the kitchen gas stove and kitchen cabinets, LPA also observed dust and debris accumulated along windows and sliding door tracks throughout the facility, including in residents rooms. Additionally LPA observed a kitchen cabinet drawer that was loose and unstable. This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Nune Margaryan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2026


LIC809 (FAS) - (06/04)
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