<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200929
Report Date: 10/18/2021
Date Signed: 10/18/2021 01:35:48 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GREEN VALLEY CARE HOMEFACILITY NUMBER:
079200929
ADMINISTRATOR:OSIA, MARJORIEFACILITY TYPE:
740
ADDRESS:116 VALDIVIA CIRCLETELEPHONE:
(925) 719-3589
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:6CENSUS: 4DATE:
10/18/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Marjorie Osia, AdministratorTIME COMPLETED:
01:55 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/18/2021 starting at 1:10 PM, Licensing Program Analyst (LPA) L. Francisco conducted a Case Management concurrently with Infection Control Inspection to discuss information obtained regarding bedridden room (Room #2). LPA met with Administrator, Marjorie Osia and explained the purpose of the visit.

Although room #2 was approved for bedridden, it was determined by Fire Inspector during an inspection completed on 10/12/2021, that room #2 does not meet Fire Code requirements for bedridden.

LPA reviewed resident's (R1) physician report and LPA observed R1 is not bedridden. LPA advised Administrator to not accept bedridden residents in room #2 until further guidance.

LPA requested to submit a copy of updated floor plan to CCL by 10/22/2021.

No deficiencies cited during visit. Exit interview conducted with Administrator. Due to technical difficulties, LPA provided a copy of report via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
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 1