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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397001567
Report Date: 08/05/2022
Date Signed: 08/05/2022 02:44:38 PM

Document Has Been Signed on 08/05/2022 02:44 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:VALLEY FORGE BOARD AND CARE HOMEFACILITY NUMBER:
397001567
ADMINISTRATOR:JOSEPH C. OFAMENFACILITY TYPE:
735
ADDRESS:3242 VALLEY FORGE DRIVETELEPHONE:
(209) 473-8516
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: DATE:
08/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Elsa OfamenTIME COMPLETED:
03:30 PM
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On 8/5/22 at 1:25pm Licensing Program Analyst (LPA) Kevin Gould arrived at Valley Forge Board and Care Home for the purpose of conducting a required 1 year annual inspection. LPA met with Licensee, Elsa Ofamen and together conducted a tour of the home.

Due to a previous inspection that took place earlier this year outside of the allotted time frame for an annual inspection LPA Gould conducted a second annual inspection to meet title 22 regulations. Due to the previous inspection LPA was not able to open this inspection as a required 1 year annual inspection and could not generate the inspection tool. LPA utilized an offline inspection tool to discuss infection control at the facility.

LPA and licensee evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA observed one (1) resident is over 60 years of age and LPA and licensee discussed the necessary documentation required for retaining a resident over the age of 60.

LPA measured the water temperature, temperature measured at 108 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2022
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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