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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200134
Report Date: 08/26/2021
Date Signed: 08/26/2021 02:11:02 PM

Document Has Been Signed on 08/26/2021 02:11 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: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:
08/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:TJ Marcelo, AdministratorTIME COMPLETED:
02:25 PM
NARRATIVE
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On 8/26/2021 at 11:15AM, Licensing Program Analysts (LPAs) G. Luk and J. Sampair arrived unannounced to conduct an Infection Control Inspection. LPAs met with staff, Kaiona Urate and explained the purpose of the visit. Administrator, TJ Marcelo arrived 20 minutes later.

LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, and outdoor areas. LPAs observed sign & symptoms, cough etiquette, and social distancing were posted in the common areas. Hand washing posters were posted at bathrooms and sinks.

During record review, LPAs observed visitors log. LPAs observed facility has a copy of Mitigation Plan. LPAs observed PPEs, food, and paper supplies are sufficient.

The following deficiencies were observed during the visit:
-At 11:45AM, LPAs observed unlocked cleaning supplies and scissors in the kitchen. Unlocked gardening tool in the backyard. Staff locked up all items during inspection.
-At 11:50AM, LPAs observed kitchen cabinet doors and living room air vent was not in good repair. Administrator stated that those items will be repaired in the next couple days.
-At 3:30PM, LPAs observed facility sketch CCLD have on file is different than facility's physical plant. LPAs requested new sketch and permits from licensee.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies may result in Civil Penalties.

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: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2021
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 08/26/2021 02:11 PM - It Cannot Be Edited


Created By: Grace Luk On 08/26/2021 at 01:26 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: VALLEY RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 019200134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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
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Based on observation, the licensee did not comply with the section cited above by having unlocked cleaning supplies, scissors, and gardening tool which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/27/2021
Plan of Correction
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Staff locked up the scissors, cleaning supplies, and gardening tools during inspection.

Deficiency cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2021


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 08/26/2021 02:11 PM - It Cannot Be Edited


Created By: Grace Luk On 08/26/2021 at 01:26 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: VALLEY RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 019200134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having kitchen cabinet doors and living room air vent in good repair which poses a potential health and safety risk to persons in care.
POC Due Date: 09/07/2021
Plan of Correction
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Administrator stated that the repair person will be fixing those items in a few days and will submit picture proof/self-certification that the repairs are completed by POC date.
Type B
Section Cited
CCR
80086(a)
Alterations to Existing Building or New Facilities
(a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not notifying CCLD of the new sketch which poses a potential health and safety risk to persons in care.
POC Due Date: 09/07/2021
Plan of Correction
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Administrator has agreed to provide new clearance and permits for the facility 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2021


LIC809 (FAS) - (06/04)
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