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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601251
Report Date: 08/26/2022
Date Signed: 08/26/2022 01:20:54 PM


Document Has Been Signed on 08/26/2022 01:20 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 IVFACILITY NUMBER:
015601251
ADMINISTRATOR:ADAMS, GISELLE V.FACILITY TYPE:
740
ADDRESS:7638 APPLEWOOD WAYTELEPHONE:
(925) 785-8748
CITY:PLEASANTONSTATE: CAZIP CODE:
94588
CAPACITY:6CENSUS: 6DATE:
08/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:06 PM
MET WITH:Gina Licup, Assistance Administrator TIME COMPLETED:
01:30 PM
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On 8/26/22 at 12:06PM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct Infection Control Inspection. LPA was greeted by care staff Hannah Bognot. Administrator was present at the time. LPA explained the purpose of the visit to care staff and asked to contact administrator. Administrator is out of town and gave verbal permission for care staff to tour the facility with LPA. Assistance Administrator Gina Licup later arrived at 12:50PM to complete the inspection.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

During record review, LPAs reviewed a sample of 4 staff records and observed 4 of 4 have health screening with TB test on file.


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2022
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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