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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600076
Report Date: 08/26/2021
Date Signed: 08/26/2021 06:33:39 PM

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:HAPPY VALLEY-HOME FOR OUR PARENTSFACILITY NUMBER:
075600076
ADMINISTRATOR:ONOFREI, NICOLAEFACILITY TYPE:
740
ADDRESS:3292 WALNUT LANETELEPHONE:
(925) 284-4846
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY:6CENSUS: 4DATE:
08/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Damaris Onofrei, AdministratorTIME COMPLETED:
06:55 PM
NARRATIVE
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On 8/26/2021 starting at 3:45pm, Licensing Program Analysts (LPAs) L. Francisco and C. Lin arrived unannounced to conduct Infection Control Inspection. LPAs met with Administrator, Damaris Onofrei and explained the purpose of the visit.

During the Infection Control Inspection, LPAs toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents and visitors. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

THE FOLLOWING DEFICIENCIES WERE OBSERVED:
  • At 3:45pm, LPAs temperature were not checked. LPAs were not screened and staff were not wearing a face covering.
  • At 4:05pm, LPAs observed unlocked knives in kitchen drawer.
  • At 4:06pm, LPAs observed centrally stored medications unlocked and key was left on the lock
  • At 4:25pm, LPAs observed unlocked disinfectants inside closet located in the dining room
  • At 4:28pm, LPAs observed unlocked laundry detergent
  • At 5:00pm during record review, LPAs observed facility does not have an Emergency Disaster Plan (LIC 610D)

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

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
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)
Page: 1 of 12
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: HAPPY VALLEY-HOME FOR OUR PARENTS
FACILITY NUMBER: 075600076
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

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. LPAs observed LPAs temperature was not checked, screened and staff were not wearing a face covering which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/27/2021
Plan of Correction
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By POC date, Administrator agrees to retrain staff and send a copy of training agenda to CCL.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, licensee did not comply with the section cited above. LPAs observed medications in kitchen cabinet was unlocked and a key was not removed from the lock which poses an immediate health, safety risk to persons in care.
POC Due Date: 08/27/2021
Plan of Correction
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Deficiency cleared during visit. LPAs observed Administrator locked and removed key from medication cabinet. In addition, Administrator will retrain staff on regulation and submit a copy of training agenda to CCL no later than 8/31/2021.
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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
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 12
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: HAPPY VALLEY-HOME FOR OUR PARENTS
FACILITY NUMBER: 075600076
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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. LPAs observed unlocked knives in the kitchen drawer which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/27/2021
Plan of Correction
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Deficiency cleared during visit. In addition, Administrator conduct training with staff of regulation and submit a copy of training agenda to CCL no later than 8/31/2021.
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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. LPAs observed unlocked disinfectants, cleaning supplies, gardening supplies and laundry detergent which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/27/2021
Plan of Correction
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LPAs observed cleaning supplies and laundry detergent were locked away. Administratoragrees to remove and store gardening supplies and submit a photo 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
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: 3 of 12
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: HAPPY VALLEY-HOME FOR OUR PARENTS
FACILITY NUMBER: 075600076
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPAs observed facility does not have a LIC 610E on file which poses a potential health and safety concern to persons in care.
POC Due Date: 09/02/2021
Plan of Correction
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By POC, Administrator will submit a copy of Emergency Disasater Plan (LIC 610E).
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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
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: 4 of 12