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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200134
Report Date: 08/17/2022
Date Signed: 08/17/2022 03:48:03 PM

Document Has Been Signed on 08/17/2022 03:48 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:TYLERJAMES A. MARCELOFACILITY TYPE:
735
ADDRESS:33389 UNIVERSITY DRIVETELEPHONE:
(510) 441-1309
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
08/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:TylerJames Marcelo, AdministratorTIME COMPLETED:
02:00 PM
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On 8/17/2022 at 12:20PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with administrator, TylerJames Marcelo.

Upon entry, LPA's temperature was checked and asked to fill out COVID-19 questionnaire. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to client's bedrooms, bathrooms, kitchen, common areas, and outdoor areas. LPA observed cough etiquette, signs & symptoms, and physical distancing are posted in the common areas. Hand washing posters were posted at sinks and bathrooms.

During record review, LPA observed visitors log and temperature log for both clients and staff. LPA observed facility has a copy of Mitigation Plan on file. Staff were FIT tested for N95 respirators and completion forms were reviewed. LPA observed PPE, food supplies, and paper supplies are sufficient.

No deficiencies cited on this date.

Exit interview conducted. A copy of this report was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2022
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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