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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601499
Report Date: 02/14/2023
Date Signed: 02/14/2023 12:24:18 PM


Document Has Been Signed on 02/14/2023 12:24 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:
02/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Leah MacDonald, AdministratorTIME COMPLETED:
12:40 PM
NARRATIVE
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On 2/14/2023 at 11:10AM, Licensing Program Analysts (LPAs) L. Alexander and G. Luk conducted an unannounced to conduct a case management visit. LPAs met with Administrator, Leah MacDonald.

While LPAs was at the facility for another visit, the following deficiency was observed.

At 10:45AM, LPAs observed front door had a door chain latch located near the top of the door. Staff informed LPAs that door chain latch was put on to prevent residents from leaving.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2023
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 02/14/2023 12:24 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: 02/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/15/2023
Section Cited

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Personal Rights of Residents in All Facilities. Residents... shall have all of the following personal rights: To leave or depart the facility at any time and to not be locked...
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Administrator removed door chain latch at front door.


Deficiency cleared.
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This requirement is not met as evidenced by: Based on observation, Licensee did not comply with the section cited above by having a door chain latch at front door which poses an immediate health and safety risk to the persons in care.
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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: 02/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2023
LIC809 (FAS) - (06/04)
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