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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200134
Report Date: 08/09/2024
Date Signed: 08/14/2024 01:39:36 PM

Document Has Been Signed on 08/14/2024 01:39 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/
DIRECTOR:		TYLERJAMES A. MARCELOFACILITY TYPE:
735
ADDRESS:33389 UNIVERSITY DRIVETELEPHONE:
(510) 441-1309
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
08/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Yolanda Tanjoco/Myra QuevedoTIME VISIT/
INSPECTION COMPLETED:
01:55 PM
NARRATIVE
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On this day at around 9:50 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct annual required inspection and met with staff Yolanda Tanjoco. LPA explained to Tanjoco the purpose of the visit. The Administrator was informed over the phone about the visit and he authorized staff Tanjoco to sign the report.

During the visit, LPA inspected the facility inside and out including but not limited to six client rooms, bathrooms, kitchen, dining and living areas and backyard. The facility appeared to be clean and odor free. There is sufficient lighting. No bodies of water were observed. Hallways and passageways were observed to be free of obstruction. Fire extinguisher that appeared full and was last serviced on 10/12/2023 was observed.

There was sufficient supply of perishable and non perishable foods. Towels, sheets and warm blankets in good repair were observed. There was one client and 3 staff observed at the facility during the visit. The remaining clients were all in their respective day programs.

At around 10:40 am, LPA reviewed 5 client and 4 staff files. All staff are fingerprint cleared. LPA observed S2 did not have TB test and health screening on file.

At 12:15 pm, LPA reviewed P&I money and log with Tanjoco. The facility has $3,000 surety bond which is sufficient to cover amount of cash being handled. Last fire drill was conducted on 6/18/24 and last earthquake drill was completed on 7/18/24.

Deficiency is cited per Title 22 California Code of Regulations (refer to Lic 809D).
Exit interview was conducted with Tanjoco and Appeal Rights was provided.
***This is an amended copy of report issued on 8/9/2024***
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2024
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 08/14/2024 02:59 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/14/2024 08:15 AM


Created By: Luisa Fontanilla On 08/09/2024 at 01:14 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: 08/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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This page is an amended copy of the report issued on 8/9/2024. After the report has been final printed, the Administrator provided LPA a copy of the surety bond in the amount of $3,000 which is sufficient to cover amount of cash being handled at one time. This deficiency is removed.
POC Due Date:
Plan of Correction
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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: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/09/2024 01:45 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 08/09/2024 at 01:25 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: 08/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review conducted, the licensee did not comply with the section cited above in not having S1 and S2 health screening on file which poses/posed a potential health, safety or personal rights risk to persons in care. Both employees have been working at the facility for more than 3 months.
POC Due Date: 08/30/2024
Plan of Correction
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S1 and S2 will obtain health screening and submit proof to CCL by POC date.
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review the licensee did not comply with the section cited above in not having S1 and S2 obtain TB test which poses/posed a potential health, safety or personal rights risk to persons in care. Both staff have been working at the facility for more than 3 months.
POC Due Date: 08/30/2024
Plan of Correction
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S1 and S2 will obtain TB test and submit proof to CCL 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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024


LIC809 (FAS) - (06/04)
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