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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202536
Report Date: 10/06/2021
Date Signed: 10/13/2021 08:42:43 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:WEST VALLEY CARE HOMEFACILITY NUMBER:
435202536
ADMINISTRATOR:ZHANG, BIAOFACILITY TYPE:
740
ADDRESS:15 DARRYL DRIVETELEPHONE:
(408) 418-8188
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:6CENSUS: 5DATE:
10/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:03 PM
MET WITH:Biao ZhangTIME COMPLETED:
06:09 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 10/06/2021 at 04:03pm. LPA met with facility Administrator Biao Zhang.

LPA toured the facility, including living room, kitchen, family room, garage, office, 4 bedrooms, 2 bathrooms, back patio, backyard, and storage sheds. All staff members observed to be wearing masks. Admin confirmed that all staff and residents have been vaccinated.

All emergency exits noted to be clear of obstruction. Bathrooms observed to have paper towels, but no liquid soap or handwashing signs. Fire extinguisher observed to be inspected on December 2019. Smoke/carbon monoxide detectors tested and observed to be operational.

Facility observed to have designated entry point. Front door not observed to have visitor policy or COVID prevention signs. Staff took LPA's temperature, but did not screen for symptoms. Facility sign in sheet noted to not have tracking log for temperature and symptom screening. Facility does not have 30-days supply of N95s and gowns. Water temperature observed to be 105.1 *F. Facility temperature observed to be 71*F. Social distancing signs not observed to be posted in all public areas of the facility.

LPA observed odor of urine in resident room. Admin stated that staff was in the process of cleaning the room, after the resident had left for a doctor's appointment that morning. Resident sheets were observed to be clean and washed. LPA found resident medication on the shelves of 2 resident rooms. Review of resident files indicate that residents are capable of administering and storing their own medication. Admin stored resident medication out of sight during inspection.

No deficiencies cited, advisory notes issued. This report was reviewed with Administrator Biao Zhang and a copy of the signed report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
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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