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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601499
Report Date: 01/17/2023
Date Signed: 02/14/2023 12:10:22 PM


Document Has Been Signed on 02/14/2023 12:10 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/07/2023 01:55 PM

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

NARRATIVE
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This is an amendment to an original report dated 01/17/23.

On 01/17/2023 at 2:50PM, Licensing Program Analysts (LPAs) L. Alexander and C. Fowler arrived unannounced to conduct a POC visit. LPAs met with Leah MacDonald Administrator and explained the purpose of the visit.

Facility has the following deficiencies that was not cleared and deficiencies were issued on 11/30/2022 from California Code of Regulations, Title 22:

LPAs observed the following deficiencies during today's POC visit:

At 2:50pm - LPAs observed S2 was not associated to facility.
At 2:56pm - LPAs observed vitamins located in created bedroom with the door unlocked.


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: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023
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 3


Document Has Been Signed on 02/14/2023 12:11 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/07/2023 02:03 PM

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: 01/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/18/2023
Section Cited

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(e) All individuals subject to a criminal record review... ...l prior to working, residing or volunteering...(2)... transfer of a... Section 87355(c)
This requirement is not met as evidenced by:
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Administrator instructed S2 to leave the premises immediately. Administrator will associate S2 before she returns to work.
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Based on interview, the licensee did not comply with the section cited above which poses an immediate health and safety rights risk to persons in care. Unassociated staff working.
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Type A
01/18/2023
Section Cited

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(f) The following shall be stored inaccessible to...
(2) Over-the-counter medication...vitamins...as certain plants, gardening supplies, cleaning supplies and disinfectants.
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Administrator will lock the vitamins and keep it inaccessible to residents in care.
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Based on LPAs observations there was vitamins sitting on the counter located in the created room in the garage.
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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: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document is an Amendment of Original Document on 02/07/2023 02:01 PM

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: 01/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)

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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: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3