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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601499
Report Date: 11/30/2022
Date Signed: 02/14/2023 11:57:53 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/14/2023 11:57 AM - 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:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Maria Christina Velasquez, CaregiverTIME COMPLETED:
06:15 PM
NARRATIVE
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This is an amendment to an original Annual Report (809) dated 11/30/22.

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.
Continue to LIC809-C
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)
Page: 1 of 4


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
VISIT DATE: 11/30/2022
NARRATIVE
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-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
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
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/14/2023 11:57 AM - 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/01/2022
Section Cited

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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:
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Administrator locked the scissors with the sharps and locked the medicine cabinet and removing the keys. Deficiency cleared during visit.
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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.
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Type A
12/01/2022
Section Cited

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All individuals subject to a criminal record review.... shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department.
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Administrator completed LIC9182 document and faxed to CCLD office. Deficiency was cleared during visit
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-This requirement is not met as evidenced by: Licensee failed to ensure all staff had a criminal record clearance. LPA observed S1 & S2 did not have a criminal record clearance, which poses a immediate safety risk to residents 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: 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 4


Document Has Been Signed on 02/14/2023 11:57 AM - 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2023
Section Cited

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Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement was not met
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By POC date, facility will submit to CCL a copy of the County permit, along with an updated facility sketch, and a formal letter explaining the alteration,.
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as evidenced by: LPA observed that a bedroom was constructed in the garage which is a potential threat to the health and safety of clients 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: 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: 4 of 4