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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200929
Report Date: 11/01/2021
Date Signed: 11/01/2021 04:00:38 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/22/2021 and conducted by Evaluator Lizette Francisco
COMPLAINT CONTROL NUMBER: 15-AS-20211022082651
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:
11/01/2021
ANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Marjorie Osia, AdministratorTIME COMPLETED:
04:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to update resident's medical assessment
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/1/2021 starting at 2:00 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct complaint investigation for the above allegation. LPA met with Administrator and explained the purpose of the visit.

During the complaint invesgiation, LPA reviewed records and interviewed Administrator. Based on information obtained, facility failed to update resident's medical assessment. During a Case Management visit on 10/18/2021, LPA reviewed two resident's (R1 and R2) physician's report and LPA observed R1's physician's report was last updated on 8/14/2020.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. Appeal rights and a copy of this report provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20211022082651
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 079200929
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/12/2021
Section Cited
CCR
87705(c)(5)
1
2
3
4
5
6
7
CARE OF PERSONS WITH DEMENTIA
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(5)Each resident with dementia shall have an annual medical assessment as specified...least annually..
1
2
3
4
5
6
7
Deficiency cleared during visit. LPA observed an updated Medical Assessment completed on 10/22/2021 for R1.
8
9
10
11
12
13
14
This requirement was not met as evidenced by: Based on record review, Licensee did not comply with regulation cited above. On 10/18/21, LPA observed R1's medical assessment was last completed on 8/14/2021 which poses a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/22/2021 and conducted by Evaluator Lizette Francisco
COMPLAINT CONTROL NUMBER: 15-AS-20211022082651

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:
11/01/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Marjorie Osia, AdministratorTIME COMPLETED:
04:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Fire Clearance
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/1/2021 starting at 2:00 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct complaint investigation for the above allegation. LPA met with Administrator and explained the purpose of the visit.

During the complaint invesgiation, LPA reviewed records and interviewed Administrator. Based on information obtained by complainaint, a bedridden resident is staying in the bedroom that is not cleared for bedridden. However on 11/1/2021, resident's (R1) latest physician report from 10/22/2021 states R1 is non-ambulatory and not bedridden.

This agency has investigated the complaint alleging fire clearance. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3