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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202536
Report Date: 11/04/2021
Date Signed: 11/04/2021 12:50:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
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:
11/04/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Biao ZhangTIME COMPLETED:
01:00 PM
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Licensing Program Analysts (LPAs) Marybeth Donovan and Christine Delores conducted an unannounced case management visit to discuss record keeping of centrally stored medications. LPA met with Biao Zhang Administrator.

During a medication audit on 08/28/2020 for an investigation and based on interview with Administrator that the centrally stored medication record start dates were not accurate. The start dates did not reflect the actual start date for medications with multiple refill bottles. When the resident is done with one bottle, the Administrator will start a new bottle. Also, the Administrator would mix medications from the existing bottle with the new prescription bottle. The actual start date was not recorded.

LPAs reviewed medication procedures and record keeping of centrally stored medications with Administrator. The Administrator stated that prescription medications bottles are not mixed and accurate medication start dates are reflected on the Centrally Stored Medication Record and each prescription bottle.

The following Advisory Note was issued see attached LIC9102 per the California Code of Regulations, Title 22.

This report was reviewed with Biao Zhang Administrator and a copy provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
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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