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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206728
Report Date: 08/24/2022
Date Signed: 08/24/2022 11:11:10 AM

Document Has Been Signed on 08/24/2022 11:11 AM - 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:VALLEY RESIDENTIAL SERVICESFACILITY NUMBER:
157206728
ADMINISTRATOR:VILLEGAS, BEATRICEFACILITY TYPE:
735
ADDRESS:5808 EDGEMONT DRTELEPHONE:
(661) 832-0214
CITY:BAKERSFIELD, CASTATE: CAZIP CODE:
93309
CAPACITY: 4CENSUS: 4DATE:
08/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Beatrice Villegas, Licensee/AdministratorTIME COMPLETED:
11:25 AM
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On 8/24/22 at 9:30 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry by staff. Licensee/Administrator Beatrice Villegas arrived a short time later.

LPA toured the inside and outside of the facility with staff. No fire issues observed. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were observed by the bathroom sinks. Bedrooms were checked and residents do not share bedrooms. LPA checked residents’ medications. Food supply was observed in adequate supply. Cleaning and PPE supplies were checked. Resident files have updated emergency contact information. Staff files checked for health assessments. Administrator certificate is valid.

The following deficiencies were observed:
1. LPA observed bedroom #1 ceiling light chains were both short and missing the end pieces, bedroom #4 top hinge nails were extended out and door was sticking when closing, both sinks in hall bathroom and sink in master bathroom had low water flow and water was spraying out, tile wall surround and floor observed with soap scum and dark mold, and exterior fire exit gate observed unsteady on both sides and gate was not closing with ease.
2. Hot water in master bedroom measured 101.8 degrees F.

The following updated forms to be sent to CCL within 2 weeks:
LIC500, LIC400, LIC402, LIC610D (new revision)

Exit interview conducted. A copy of this report and a Plan of Correction was reviewed and developed with Licensee Beatrice Villegas, whose signature confirms receipt of this report.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2022
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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Document Has Been Signed on 08/24/2022 11:11 AM - It Cannot Be Edited


Created By: Malia Thao On 08/24/2022 at 10:46 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: VALLEY RESIDENTIAL SERVICES
FACILITY NUMBER: 157206728

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed bedroom #1 ceiling light chains were both short and missing the end pieces, bedroom #4 door top hinge nails were extended out and door was sticking when closing, both sinks in hall bathroom and sink in master bathroom had low water flow and water was spraying out, tile wall surround and floor observed with soap scum and dark mold, and exterior fire exit gate observed unsteady on both sides and gate was not closing with ease, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2022
Plan of Correction
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Licensee will submit proof to CCL by POC due date of ceiling light chains in bedroom #1 replaced, top hinge of bedroom #4 door repaired and door closing with ease, both sink faucets in hall bathroom and sink faucet in master bathroom replaced, tile wall surround and floor cleaned of soap scum and mold, and exterior fire exit gate completely replaced with gate opening/closing with ease. LPA will return for a POC visit.
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Hot water in master bedroom measured 101.8 degrees F, which poses a potential health or personal rights risk to persons in care.
POC Due Date: 08/25/2022
Plan of Correction
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Licensee will submit proof of hot water in master bathroom measuring within regulation to CCL 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.
SUPERVISOR'S NAME:Melinda Hoffmann
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022


LIC809 (FAS) - (06/04)
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