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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200134
Report Date: 10/08/2024
Date Signed: 10/08/2024 10:15:22 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:
10/08/2024
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Justin Lam, staffTIME COMPLETED:
09:25 AM
ALLEGATION(S):
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Facility is not following resident’s IPP/ ISP plan.
Staff not meeting resident’s health care needs.
INVESTIGATION FINDINGS:
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On 10/8/2024 at 8:45AM, Licensing Program Analysts (LPAs) G. Luk and P. Manalo arrived unannounced to deliver findings in regards to the allegations above. LPAs met with staff, Justin Lam and explained the purpose of the visit. LPAs spoke with Administrator, TylerJames Marcelo and stated that staff can sign CCLD reports.

During the course of investigation, LPA interviewed 3 clients, 5 staff, witnesses, 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).

Facility is not following resident’s IPP/ ISP plan.
C2’s IPP indicated that facility will continue to schedule and keep client’s regular and urgent care medical/dental appointments. However, C2 did not have medical or dental appointment scheduled in 2020. (Continue on LIC9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
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 3
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: 10/08/2024
NARRATIVE
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Staff not meeting resident’s health care needs.
C2’s medical records indicated C2 had a physical exam on 10/18/2019, dental clinic visit on 8/18/2021, lab test on 5/5/2022. C2’s IPP indicated that facility will schedule C2’s dental and medical appointments to ensure C2 continues to remain in good health. However, LPA observed C2 did not have lab tests or physical exam in 2020 and 2021. Additionally, C2 did not have dental exam or dental cleaning in 2020.

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: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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: 10/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2024
Section Cited
CCR
85078(a)(1)
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Responsibility for Providing Care and Supervision. The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs. This requirement is not met as evidence by:
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Facility has agreed to create a plan to ensure client's IPP/ISP plans are met and submit 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 following client IPP/ISP plan which poses a potential health and safety risk to the persons in care
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Type B
10/25/2024
Section Cited
CCR
80078(a)
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Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the client's needs.This requirement is not met as evidence by:
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Facility has agreed to create a plan to ensure client's health care needs are met and submit 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 meeting the client's health care needs 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: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3