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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601499
Report Date: 11/30/2022
Date Signed: 11/30/2022 05:51:15 PM


Document Has Been Signed on 11/30/2022 05:51 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:RELIEZ VALLEY CARE HOMEFACILITY NUMBER:
075601499
ADMINISTRATOR:MACDONALD, LEAHFACILITY TYPE:
740
ADDRESS:656 STERLING DRIVETELEPHONE:
(925) 370-6425
CITY:MARTINEZSTATE: CAZIP CODE:
94553
CAPACITY:6CENSUS: 4DATE:
11/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Maria Christina Velasquez, CaregiverTIME COMPLETED:
06:15 PM
NARRATIVE
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On 11/30/22 at 2:40 PM, Licensing Program Analysts (LPAs) L. Alexander and C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPAs was greeted by, Caregiver, Maria Christina Velasquez, and explained the purpose of the visit. Leah MacDonald, arrived approximately at 3:32 PM.

Upon entry, LPA's temperature was not checked. LPAs observed screening station that contained hand sanitizer, masks and COVID signage. LPAs toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. LPAs observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing posters.

During record review, LPAs observed visitors log and temperature logs for residents or staff. LPAs observed facility has a copy of Mitigation Plan on file.

The following deficiencies were observed during the visit:

-At 2:42 PM, LPAs observed S2 was not associated to facility.
-At 2:43 PM, LPAs observed a pair of scissors laying on kitchen counter top.
-At 2:44 PM, LPAs observed keys in top kitchen cabinet that contained medication.
-At 3:16 PM, LPAs observed a created bedroom in the garage.
-At 3:20 PM, LPAs observed a created bedroom out of the dining room connected to the kitchen

The 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. A copy of this report and appeal rights provided.


Continued on LIC809D.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022
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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Document Has Been Signed on 11/30/2022 05:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: RELIEZ VALLEY CARE HOME
FACILITY NUMBER: 075601499

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)(2)
87705 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).
(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 by having scissors on the kitchen counter and keys hanging from the medicine cabinet accessible to residents in care which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/01/2022
Plan of Correction
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Administrator locked the scissors with the sharps and locked the medicine cabinet and removing the keys. Deficiency cleared during visit.
Type A
Section Cited
CCR
87355(e)(2)
87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

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 by not associating S2 to the facility which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/01/2022
Plan of Correction
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Administrator completed LIC9182 document and faxed to CCLD office. Deficiency was cleared during visit

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: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3


Document Has Been Signed on 11/30/2022 05:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: RELIEZ VALLEY CARE HOME
FACILITY NUMBER: 075601499

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(A)
87208((A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended...7)Sketches, showing dimensions, of the following:

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 creating a bedroom in the garage being used for accommodation. In addition, to creating a bedroom out of the dining room connected to the kitchen without a permit, which poses a potential health and safety risks to persons in care
POC Due Date: 12/30/2022
Plan of Correction
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Administrator agreed to obtain a permit for the two additional bedrooms created at the facility. Administrator will send proof of permits to CCLD no later then the POC date.

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: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3