015601039-5-2-2024-15-AS-CFOR-D4VUXM-20240502155835

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601039
Report Date: 05/02/2024
Date Signed: 05/02/2024 03:58:52 PM

Document Has Been Signed on 05/02/2024 03:58 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	VALLE VERDE CARE HOME II		FACILITY NUMBER:	015601039
ADMINISTRATOR:	GISELLE V. ADAMS		FACILITY TYPE:	740
ADDRESS:	7851 DIANA LANE		TELEPHONE:	(925) 785-8748
CITY:	DUBLIN	STATE: CA	ZIP CODE:	94568
CAPACITY:	6	CENSUS: 4	DATE:	05/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	SHERWIN AGUSTIN, CARE STAFF		TIME COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 5/02/2024 at 12:50pm, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Sherwin Agustin, Caregiver, and explained the purpose of the visit. Giselle Adams arrived at 2:15pm. The Administrator currently holds a certificate (#7001647740) that expires on 07/30/2025. The facility’s fire clearance was approved for six (6) non-ambulatory residents. LPA toured the facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of six (6) total bedrooms which one (1) bedroom is occupied by staff, and two (2) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 108.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non skid mats. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 07/14/2023. Emergency Disaster Plan was last posted on 4/2/2024. First aid kit was observed to be complete. LPA reviewed four (4) staff files and three (3) resident files, which were all found to be complete.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

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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Document Has Been Signed on 05/02/2024 03:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: VALLE VERDE CARE HOME II	FACILITY NUMBER: 015601039
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 by having a broken lock on a cabinet under the kitchen sink which had chemicals, Lysol and cascade and laundry detergent in an unlocked garage which poses an immediate health and safety risk to persons in care.
	POC Due Date: 05/03/2024
	Plan of Correction
1 2 3 4	Administrator agreed to repair the lock and keep all chemicals locked at all times. Administrator will repair or replace lock and lock the laundry detergents in a cabinet and submit photos to CCLD by POC date.

Type A

Section Cited

CCR

87465(h)(2)

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. 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 by having unlocked medication in an unlocked drawer located in the kitchen and residents rooms which poses an immediate health and safety risk to persons in care.
	POC Due Date: 05/03/2024
	Plan of Correction
1 2 3 4	Administrator will repair or replace the lock on the drawer in the kitchen and removed the medication from residents bedroom. Administrator will submit pictures to CCLD by POC date.

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

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/02/2024 03:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: VALLE VERDE CARE HOME II	FACILITY NUMBER: 015601039
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

(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 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 by having paint, commode, branches, walker, sm table, 2 recliners, plastic drawers, shopping cart, kayak boat and a freezer located in the front, back and side yard which poses a potential health and safety risk to residents in care.
	POC Due Date: 05/24/2024
	Plan of Correction
1 2 3 4	Administrator agreed to haul away the paint, commode, branches, walker, sm table, 2 recliners, plastic drawers, shopping cart, kayak boat and a freezer from the back, side and front yard. Administrator will provide photo copies to CCLD no later then the POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

LIC809 (FAS) - (06/04)

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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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: VALLE VERDE CARE HOME II	FACILITY NUMBER: 015601039
	VISIT DATE: 05/02/2024

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Continue from LIC 809

LPA observed the following deficiencies:

· At 1:02pm, LPA observed medication and Clorox wipes in residents room.
· At 1:05pm, LPA observed Lysol and cascade in a unlocked cabinet underneath kitchen sink.
· At 1:10pm, LPA observed resident medication in an unlocked drawer located in the kitchen.

At 1:13pm LPA observed paint, commode, branches, walker, sm table, 2 recliners, plastic drawers, shopping cart, kayak boat and a freezer from the back, side and front yard

LPA requested the following documents to be submitted to CCLD by 5/10/2024.

· Resident Roster
· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 pages)
· Liability Insurance

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

LIC809 (FAS) - (06/04)

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