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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200134
Report Date: 07/19/2023
Date Signed: 07/26/2023 04:30:28 PM

Document Has Been Signed on 07/26/2023 04:30 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:
07/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Myra Quevedo, Asst AdministratorTIME COMPLETED:
02:40 PM
NARRATIVE
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On this day at around 9:10 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with Assistant Administrator Myra Quevedo. LPA explained to Quevedo the purpose of the visit. Administrator Tyler James Marcelo was informed about the visit.

During the visit, LPA observed 3 clients in the van getting ready to go to their respective day programs. Two clients went to the laboratory for blood work and one client stayed at the facility. Quevedo states the client just graduated from high school.

LPA inspected the facility inside and out including but not limited to client bedrooms, bathrooms, kitchen, dining area, backyard and living area. The facility was observed clean and odor free. There was sufficient lighting throughout the facility. No bodies of water were observed. Chemicals and medications were all locked in different cabinets. There was sufficient supply of perishable and non-perishable foods. Sufficient blankets, sheets, towels, hand towels were observed. Fire extinguisher in the kitchen area was observed to be full and last inspected on 10/4/2022. First aid kit was observed complete and updated. Smoke detectors were tested and observed operational.

Last fire drill was conducted on 6/28/2023 and last earthquake drill was done on 7/15/2023.

At around 10:15 am, LPA reviewed 5 client files and 5 staff files. At 11:20 am, LPA interviewed 2 staff and 2 clients. At 12:45 pm, LPA reviewed medications with Quevedo. At 1:24 pm, LPA reviewed P&I money and log. Facility has surety bond sufficient to cover amount of cash being handled at one time.

At around 11:45 am, LPA observed a pink pill under the dining table. Please refer to Lic 809D.
Exit interview was conducted with Quevedo and Appeal Rights was provided.
This is an amended copy from the report issued on 7/19/2023.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2023
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 07/26/2023 04:31 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/26/2023 08:05 AM


Created By: Luisa Fontanilla On 07/19/2023 at 02:06 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
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: 07/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)


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 in having an unlocked pill accessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2023
Plan of Correction
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Staff locked pill during the visit. Administrator will conduct staff training of Sec 80087(g) and submit proof to CCL
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023


LIC809 (FAS) - (06/04)
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