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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202536
Report Date: 10/13/2022
Date Signed: 10/13/2022 12:04:02 PM


Document Has Been Signed on 10/13/2022 12:04 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: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: 6DATE:
10/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Biao ZhangTIME COMPLETED:
12:04 PM
NARRATIVE
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 10/13/2022 at 10:03am. 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, and liquid soap, but no hand washing signs. Fire extinguisher observed to be inspected on December 2021. Smoke/carbon monoxide detectors tested and observed to be operational. Facility observed to have designated entry point. Staff took LPA's temperature, but did not screen for symptoms. Facility sign in sheet noted to not have tracking log for symptom screening. Facility does not have 30-days supply of N95s and gowns. Water temperature observed to be 105.0 *F. Facility temperature observed to be 71*F.

During inspection of facility bathroom, LPA observed Lysol on bathroom counter top. Admin placed Lysol bottle under the bathroom sink, where other cleaning supplies were observed. Bathroom is accessible and utilized by residents with dementia at the facility. Admin stated that the cleaning supplies belonged to an independent resident that liked to keep his bathroom clean. LPA further observed detergent and laundry pods accessible to residents in the facility garage which is unlocked. Admin placed laundry supplies in a locked cabinet with other laundry supplies.

Deficiency 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: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
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 6


Document Has Been Signed on 10/13/2022 12:04 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: WEST VALLEY CARE HOME
FACILITY NUMBER: 435202536

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2022
Section Cited

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87705 - Care for Persons with Dementia - (f) The following shall be stored inaccessible to residents with dementia: (2)...cleaning supplies and disinfectants. This requirement was not met as evidences by:
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Based on LPA observation, cleaning supplies were accessible to residents with dementia in facility bathroom and in unlocked facility garage. This posed a potential risk to the health and safety of residents in care.
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Licensee to provide proof of correction by POC due date.

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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: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
LIC809 (FAS) - (06/04)
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