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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
075601499
Report Date:
12/05/2024
Date Signed:
12/05/2024 02:22:43 PM
Document Has Been Signed on
12/05/2024 02:22 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 HOME
FACILITY NUMBER:
075601499
ADMINISTRATOR/
DIRECTOR:
MACDONALD, LEAH
FACILITY TYPE:
740
ADDRESS:
656 STERLING DRIVE
TELEPHONE:
(925) 370-6425
CITY:
MARTINEZ
STATE:
CA
ZIP CODE:
94553
CAPACITY:
6
TOTAL ENROLLED CHILDREN:
0
CENSUS:
4
DATE:
12/05/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:
Joanna Magalong, Caregiver
TIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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On 12/05/2024 at 9:25 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregivers,
Marilyn Magalued
and
Joanna Magalong
and explained the purpose of the visit. Marilyn phoned the Licensee/Administrator, Leah MacDonald to inform. The facility’s fire clearance was approved for capacity of six (6) all non-ambulatory residents. Hospice waiver approved for two (2) residents. Administrator Certificate #
7004457740 expires 05/11/2024.
LPA toured facility with Joanna including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of five (5) total bedrooms which four (4) bedrooms are occupied by the residents and one (1) bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 76 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 129.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.
Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 03/01/2024. Emergency Disaster Plan was last posted in 2023. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 10/01/2024.
LIC809-C Continued...
Bennett Fong
TELEPHONE:
(510) 725-7919
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
DATE:
12/05/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/05/2024
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
10
Document Has Been Signed on
12/05/2024 02:22 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:
12/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in by having the water temperature measuring at 129.2 F in shared bathroom which poses an immediate health and safety risk to persons in care.
POC Due Date:
12/06/2024
Plan of Correction
1
2
3
4
Administrator agreed to lower the temp and/or submit a photo of water temperature at required levels or signage of HOT water to CCLD by POC due date. During visit, Administrator posted "Caution Hot Water" sign. Deficiency cleared.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
TELEPHONE:
(510) 725-7919
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
DATE:
12/05/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/05/2024
LIC809
(FAS) - (06/04)
Page:
2
of
10
Document Has Been Signed on
12/05/2024 02:22 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:
12/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in by not having a health screening and negative TB results for S2 and S4 signed by licensed physician which poses a potential health and safety risk to persons in care.
POC Due Date:
01/02/2025
Plan of Correction
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2
3
4
Administrator agreed to submit copy of health screening and TB results for S2 and S4 to CCLD by POC due 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.
Bennett Fong
TELEPHONE:
(510) 725-7919
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
DATE:
12/05/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/05/2024
LIC809
(FAS) - (06/04)
Page:
3
of
10
Document Has Been Signed on
12/05/2024 02:22 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:
12/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in by not having range stove removed in side outside backyard which poses a potential health and safety risk to persons in care.
POC Due Date:
01/02/2025
Plan of Correction
1
2
3
4
Administrator agreed to remove range stove and send a photo of item removed to CCLD by POC due date.
Section Cited
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review the licensee did not comply with the section cited above in by having a doctor's order for 1/2 bed rail/hospital bed for R4 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/02/2025
Plan of Correction
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2
3
4
Administrator agreed to submit a copy of doctor's order for 1/2 bed rail/hospital bed for R4 to CCLD by POC due 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.
Bennett Fong
TELEPHONE:
(510) 725-7919
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
DATE:
12/05/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/05/2024
LIC809
(FAS) - (06/04)
Page:
4
of
10
Document Has Been Signed on
12/05/2024 02:22 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:
12/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in by having a report for R2's oxygen on file that was sent to local fire dept. which poses a potential health and safety risk to persons in care.
POC Due Date:
12/12/2024
Plan of Correction
1
2
3
4
Administrator agreed to send a copy of letter sent to local fire jurisdiction for R2's oxygen in use to CCLD by POC due date.
Section Cited
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in by not having "No Smoking-Oxygen in Use" signage in appropriate areas which poses a potential health and safety risk to persons in care.
POC Due Date:
12/12/2024
Plan of Correction
1
2
3
4
Administrator agreed to post signs and send a photo to CCLD by POC due date. While at facility during visit, Administrator posted signs on resident's bedroom door and outside front door. Deficiency cleared.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
TELEPHONE:
(510) 725-7919
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
DATE:
12/05/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/05/2024
LIC809
(FAS) - (06/04)
Page:
5
of
10
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:
12/05/2024
NARRATIVE
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LIC809-C (Page 2)
LPA reviewed four (4) residents records. LPA reviewed four (4) staff records and four (4) of four (4) have current first aid training and associated to the facility.
THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
At 12:15pm, LPA observed the hot water temp. was measuring 129.2 in shared bathrooms.
At 12:31pm, LPA observed range stove located outside in the side backyard.
The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.
Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 12/12/2024:
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) 725-7919
LICENSING EVALUATOR NAME:
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE:
12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/05/2024
LIC809
(FAS) - (06/04)
Page:
9
of
10
Document Has Been Signed on
12/05/2024 02:22 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:
12/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
87212 (a) Emergency Disaster Plan
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in by not having an updated Emergency Disaster Plan (LIC 610E) available which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/02/2025
Plan of Correction
1
2
3
4
Administrator agreed to submit a copy of updated Emergency Disaster Plan and submit to CCLD for review by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
TELEPHONE:
(510) 725-7919
Lori Alexander-Washington
TELEPHONE:
(510) 285-3934
DATE:
12/05/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/05/2024
LIC809
(FAS) - (06/04)
Page:
10
of
10