015601199-11-6-2024-15-AS-GLUK-DAS4AZ-20241106175645

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601199
Report Date: 11/06/2024
Date Signed: 11/06/2024 05:56:55 PM

Document Has Been Signed on 11/06/2024 05:56 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	VALLE VERDE CARE HOME III		FACILITY NUMBER:	015601199
ADMINISTRATOR/ DIRECTOR:	ADAMS, GISELLE V.		FACILITY TYPE:	740
ADDRESS:	6502 VIA SAN BLAS		TELEPHONE:	(925) 484-8468
CITY:	PLEASANTON	STATE: CA	ZIP CODE:	94566
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	11/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Giselle Adams, Administrator Olivia Aquino, Caregiver		TIME VISIT/ INSPECTION COMPLETED:	06:15 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 11/6/2024 at 1:15PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with caregiver, Olivia Aquino and explained the purpose of the visit. Administrator, Giselle Adams arrived an hour later, but was unable to stay to sign the reports and authorized caregiver to sign licensing reports. LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide combination detectors were observed. Fire extinguisher was observed to be full and last serviced on 7/19/2024. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 116.4 degrees F in the hallway bathroom. LPA observed grab bars and non-skid mat in the bathrooms. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. First Aid kit is complete. Last fire drill was conducted on 10/15/2024. LPA reviewed 6 residents and 3 staff files starting at 2:10PM. LPA reviewed a sample of resident's medications. LPA interviewed 2 staff during inspection. At 1:40PM, LPA observed unlocked medications in the kitchen drawer. Staff locked up the medication during inspection. At 1:45PM, LPA observed unlocked cleaning supplies in cabinet under the kitchen sink. The lock was not re-installed after cabinet was painted. At 3:20PM, LPA observed R6 was in room 3 and records indicates that R6 is bedridden. Facility does not have a bedridden fire clearance. (Continue on LIC809C...)

Harpreet Humpal	TELEPHONE: (510) 285-3928
Grace Luk	TELEPHONE: (510) 286-4201
	DATE: 11/06/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/06/2024 05:56 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: VALLE VERDE CARE HOME III	FACILITY NUMBER: 015601199
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by having a bedridden resident without a bedridden fire clearance which poses an immediate health and safety risk to persons in care.
	POC Due Date: 11/07/2024
	Plan of Correction
1 2 3 4	LPA received a copy of the updated facility sketch. Facility has agreed to notify the fire department. Facility will submit proof of notification and LIC200 to CCLD by POC date. Civil penalty of $500 is assessed for fire clearance violation.

Section Cited

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 by having unlocked cleaning supplies under the kitchen sink which poses an immediate health and safety risk to persons in care.
	POC Due Date: 11/07/2024
	Plan of Correction
1 2 3 4	Facility has agreed to re-install lock on the cabinet under the kitchen sink and submit picture proof to CCLD by POC 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.

Harpreet Humpal	TELEPHONE: (510) 285-3928
Grace Luk	TELEPHONE: (510) 286-4201
	DATE: 11/06/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: VALLE VERDE CARE HOME III	FACILITY NUMBER: 015601199
	VISIT DATE: 11/06/2024

NARRATIVE

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At 4:29PM, LPA observed R1's vitamin D3 is 400 unit indicated in the doctor's order. However, LPA observed vitamin D3 bottle given was 2000 unit. R1 was given multi-vitamins and have acetaminophen without doctor's order.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted with Olivia Aquino. A copy of this report, civil penalty, and appeal rights was provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 11/06/2024 05:56 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: VALLE VERDE CARE HOME III	FACILITY NUMBER: 015601199
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. 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 by having unlocked medications in the kitchen drawer which poses an immediate health and safety risk to persons in care.
	POC Due Date: 11/07/2024
	Plan of Correction
1 2 3 4	Staff locked up the medications during inspection. Deficiency cleared.

Section Cited

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not following doctor's order for R1's medication which poses an immediate health and safety risk to persons in care.
	POC Due Date: 11/07/2024
	Plan of Correction
1 2 3 4	Facility has agreed to obtain correct vitamin D3 for R1 and obtain doctor's order for R1's multi-viatimins and acetaminophen. Facility will submit picture proof and request for doctor's order to CCLD by POC 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.

Harpreet Humpal	TELEPHONE: (510) 285-3928
Grace Luk	TELEPHONE: (510) 286-4201
	DATE: 11/06/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024

LIC809 (FAS) - (06/04)

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