019200134-1-26-2023-15-AS-KHOS-CNLL6Y-20230131072930

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200134
Report Date: 01/26/2023
Date Signed: 01/26/2023 05:28:22 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/25/2022 and conducted by Evaluator Catherine Lin

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220725142221

FACILITY NAME:	VALLEY RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	019200134
ADMINISTRATOR:	LUZ MELENDEZ		FACILITY TYPE:	735
ADDRESS:	33389 UNIVERSITY DRIVE		TELEPHONE:	(510) 441-1309
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	6	CENSUS: 5	DATE:	01/26/2023
		UNANNOUNCED	TIME BEGAN:	04:45 PM
MET WITH:	Maria Corajon, staff		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

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Staff did not respond to residents' call for assistance
Staff not trained
Staff use resident to care for other resident
Facility van is dirty
Staff require resident to remain in their room
Staff do not provide activities for residents in care

INVESTIGATION FINDINGS:

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On 1/26/23 at 4:45pm, Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced subsequent complaint investigation regarding the above allegations and deliver investigation findings. LPA met with staff and explained the purpose of the visit. LPA spoke with the Administrator over the phone, Administrator authorized staff to sign on the report.

Allegation: Staff did not respond to residents' call for assistance – unsubstantiated
The Department has investigated this allegation and per interviews and records review, found that staff denied the alleged violation. R1 didn’t confirm if R1 called the staff for help in subject time period. R1 stated that R1 only liked R6 to help. R6 witnessed that R1 refused S4 to help when incident was occurred, S4 called S2 to come to facility.

Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20220725142221

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: VALLEY RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 019200134
	VISIT DATE: 01/26/2023

NARRATIVE

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Allegation: Staff not trained – unsubstantiated
The Department has investigated this allegation and per interviews and record review, found that staff received in-service training for various topics in both reviewed years 2021 and 2022 on file. The in-service training records indicated training topic, date, and staff’s signatures. The training topics were related to infection control, medication, food, safety, P&I and expenses, sanitation, grocery shopping, behavior management, activities, and first aid.

Allegation: Staff use resident to care for other resident – unsubstantiated
The Department has investigated this allegation and per interviews and record review, found that staff denied using client to care for other client. Client R1 stated that R1 liked to ask another client R6 to help because R1 didn’t like other staff. R6 confirmed that R1 always called R6 for help. R6 stated that R6 has had refused to help R1 however R1 continued to ask R6 for help. No other witness and supporting documents of the alleged violation were found.

Allegation: Facility van is dirty – unsubstantiated
The Department has investigated this allegation and per interviews and observation, found that the sanitary level of the van was acceptable. Inside the van, there were a few of un-removable stains on the seats, a little food crumps and leaves on the carpet, and no extra stuff was inside the vehicle. A thin layer of dust outside the vehicle was observed. Staff and client stated that the van got dirty easily as it has been used by staff and clients multiple times daily. Client R6 stated that staff vacuumed and washed it weekly and R6 has had helped washing it with the administrator on weekend. In the multiple visits, only one van was observed, no other vehicle using for clients was identified.

Allegation: Staff require resident to remain in their room – unsubstantiated
The Department has investigated this allegation and per interviews, found that client R1 didn’t confirm staff required clients to remain in their rooms. Staff and clients R4 and R6 stated that clients were allowed to stay outside of their room but preferred staying in their room most of the time. R6 remembered that he has had hanged out with other clients in the living room after dinner.

Continue 9099-C

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20220725142221

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: VALLEY RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 019200134
	VISIT DATE: 01/26/2023

NARRATIVE

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Allegation: Staff do not provide activities for residents in care – unsubstantiated
The Department has investigated this allegation and per interviews and record review, found that a daily activities board where indicated the current week schedules was hanged on the wall of the living room. Clients R1, R4 and R6 stated that staff took them out for walking and shopping.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to provide the alleged violations did occur, therefore the allegations are unsubstantiated.

No deficiencies cited. Exit interview conducted with staff and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

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