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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200134
Report Date: 07/27/2023
Date Signed: 07/27/2023 11:38:41 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/27/2022 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220127111418
FACILITY NAME:VALLEY RESIDENTIAL CARE FACILITYFACILITY NUMBER:
019200134
ADMINISTRATOR:LUZ MELENDEZFACILITY TYPE:
735
ADDRESS:33389 UNIVERSITY DRIVETELEPHONE:
(510) 441-1309
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 6DATE:
07/27/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Samantha David, CaregiverTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Facility not meeting resident’s dental care needs.
Staff did not schedule a medical appointment for resident
INVESTIGATION FINDINGS:
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On 7/27/2023 at 9:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPA met with Caregiver, Samantha David and explained the purpose of the visit.

During the course of investigation, LPA interviewed 3 clients, 5 staff, witness, and complainant. LPA reviewed and obtained documents (physician's report, IPP, ISP, emergency information, medical & dental documents, email correspondence, incident reports, and care notes).

Facility not meeting resident’s dental care needs.
According to dental documents, C2 had dental appointments in November 2019 and a couple dates in 2021. However, C2 did not have any dental appointments in year 2020. Email correspondence revealed that facility contacted the dental office once in year 2020 regarding C2's dental appointment.
(Continue on 9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20220127111418
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: VALLEY RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 019200134
VISIT DATE: 07/27/2023
NARRATIVE
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Staff did not schedule a medical appointment for resident
Email correspondence revealed that facility contacted C2's doctor's office a couple times in 2019 and once in 2020 regarding C2's appointments. However, C2 did not have appointments scheduled in year 2020. C2 had medical appointment in March 2021.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20220127111418
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: VALLEY RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 019200134
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/17/2023
Section Cited
CCR
85075(b)
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Health-Related Services. The facility shall ...implement a plan which ensures that assistance is provided to the clients in meeting their...dental needs. This requirement is not met evidence by:
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 Facility has agreed to submit a written plan to ensure that clients will have dental appointments scheduled. Facility will submit a copy of the written plan to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not having dental appointments made for C2 in 2020 which poses a potential health and safety risk to the persons in care.
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Type B
08/17/2023
Section Cited
CCR
80075(a)
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Health Related Services. The licensee shall ensure that each client receives necessary medical or dental services... This requirement is not met evidence by:
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 Facility has agreed to submit a written plan to ensure that clients will have medical appointments scheduled. Facility will submit a copy of the written plan to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not having dental medical appointments made for C2 in 2020 which poses a potential health and safety risk to the persons 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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/27/2022 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220127111418

FACILITY NAME:VALLEY RESIDENTIAL CARE FACILITYFACILITY NUMBER:
019200134
ADMINISTRATOR:LUZ MELENDEZFACILITY TYPE:
735
ADDRESS:33389 UNIVERSITY DRIVETELEPHONE:
(510) 441-1309
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 6DATE:
07/27/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Samantha David, CaregiverTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Staff not following physician’s oral care instructions
Staff did not ensure resident was provided with appropriate shoes.
Staff serving resident’s meals at an unreasonable time.
Staff falsified resident’s ISP plan.
Staff illegally evicted resident.
INVESTIGATION FINDINGS:
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***This is an amended copy of report issued on 7/27/2023***
On 7/27/2023 at 9:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPA met with Caregiver, Samantha David and explained the purpose of the visit.

During the course of investigation, LPA interviewed 3 clients, 5 staff, witness, and complainant. LPA reviewed and obtained documents (eviction notices, physician's report, IPP, ISP, emergency information, medical & dental documents, email correspondence, incident reports, care notes, and hospital medical and dental records).

Staff not following physician’s oral care instructions
Interview with staff revealed that staff assist C2 in brushing teeth at least twice daily. After reviewing tooth brushing log, C2 was assisted with brushing teeth three times daily. (Continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20220127111418
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: VALLEY RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 019200134
VISIT DATE: 07/27/2023
NARRATIVE
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***This is an amended copy of report issued on 7/27/2023***
Dental records obtained did not indicate C2 was prescribed specific toothpaste for oral care.

Staff did not ensure resident was provided with appropriate shoes.
Interview with staff revealed that C2 has both Velcro and shoelace shoes. Staff stated that C2 sometimes pick the shoes she would like to wear for the day.

Staff serving resident’s meals at an unreasonable time.
Interview with staff revealed that breakfast is served either before or after daily showers for C2. Staff stated that breakfast is usually around 8-9AM.

Staff falsified resident’s ISP plan.
ISP (Individual Service Plan) are created by a behaviorist with client’s historical information provided by the facility. Interview with witness and staff revealed that C2’s historical and adaptive skills baseline information including doctor’s appointments were obtained from C2’s referral packet, IPP, and facility binder. W3 stated the adaptive skills baseline was either from information provided by facility staff, through client observations, or previous ISP. S1 stated that C2’s family informed S1 regarding corrections needed in C2’s ISP and changes were made to C2’s ISP. After interviewing staff, some staff stated that C2 can brush teeth on her own with verbal prompting and some staff stated that C2 needs assistance for brushing teeth.

Staff illegally evicted resident.
Interview with staff and complainant revealed that C2 was give two 30-day eviction notices in 2021. However, C2 was not kicked out of the facility. RCEB (Regional Center of East Bay) was able to find placement and C2 was relocated to another facility in February 2022.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5