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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430702352
Report Date: 09/24/2024
Date Signed: 09/24/2024 04:46:12 PM


Document Has Been Signed on 09/24/2024 04:46 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:VALLEY PINESFACILITY NUMBER:
430702352
ADMINISTRATOR:HEINAN, JAMESFACILITY TYPE:
740
ADDRESS:545 EAST MAIN AVENUETELEPHONE:
(408) 779-2855
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:49CENSUS: 17DATE:
09/24/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Carolyn and James HeinanTIME COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct an unannounced case management – deficiencies. LPA met with Licensees Carolyn and James Heinan. On 09/16/2024, LPA Dolores arrived to the facility to open the initial complaint investigations for complaint control numbers 26-AS-20240910121029 and 26-AS-20240912155005. During the complaint investigations, Title 22 violations were observed.

On 09/16/2024, LPA Dolores was informed of a resident (R1) who passed away in March 2024. LPA Dolores reviewed the facility’s file and did not observe an incident report and death report was received by the licensing department. Licensee produced the incident report from R1's file from March 2024 stating R1 was sent to the hospital. Licensee was unable to produce documentation to show the incident report or death report was submitted to the licensing department.

On 09/16/2024, LPA Dolores obtained records for 2 complaint investigations. Based on interview, the Licensee's observed resident (R2) had a change of condition from ambulatory to bedridden. It was stated that the resident also required a two-person assist during transfers. The review of R2’s records show the physician’s report was last updated on 09/16/2022, which does not indicate the change of condition and updated ambulatory status. R2’s appraisal/needs and services plan was last developed during admission on 09/18/2022.

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SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: VALLEY PINES
FACILITY NUMBER: 430702352
VISIT DATE: 09/24/2024
NARRATIVE
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The Licensee updated R2's appraisal/needs and services plan on 09/10/2024 stating the resident is bedridden, but the appraisal/needs and services plan was not reviewed and acknowledged by R2 and/or R2's responsible party. There was also no indication that R2 required a two-person assist.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809D.

This report was reviewed with Licensees Carolyn and James Heinan and a copy of the report and appeal rights were provided.

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SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/24/2024 04:46 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: VALLEY PINES
FACILITY NUMBER: 430702352

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2024
Section Cited
CCR
87211(a)

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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by:
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Licensee states they will submit a statement of understanding of the section cited. Licensee will also submit a plan in writing to ensure all fax cover sheets will be attached to incident reports and death reports.
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Based on interview, record review, and observation the licensee did not ensure to submit a written incident report and death report to the licensing Department for R1 during an incident that occurred in March 2024 which poses a potential health, safety and personal rights risk to persons in care.
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Licensee will submit the plan of correction to LPA Dolores via fax by 10/01/2024.
Type B
10/01/2024
Section Cited
CCR87505

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Each facility shall document in writing the findings of the pre-admission appraisal and any reappraisal or assessment which was necessary in accordance with Sections 87457, Pre-admission Appraisal, and 87463, Reappraisals. If supporting documentation from a physician is required, this input shall also be obtained and may be the same assessment as required in Section 87458, Medical Assessment. This requirement is not met as evidenced by:
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Licensee will submit R2's updated physician's report and appraisal/needs and services plan that will be reviewed by R2's responsible party to LPA Dolores via fax by 10/01/2024.
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Based on interview, record review and observation the licensee did not ensure to update R2's reappraisal and physician's report upon a change on condition based on the licensee's observations which poses a potential health, safety and personal rights risk to persons in care.
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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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
LIC809 (FAS) - (06/04)
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