435202536-10-30-2024-26-AS-MTAN-DAJRSX-20241030131727

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202536
Report Date: 10/30/2024
Date Signed: 10/30/2024 01:18:04 PM

Document Has Been Signed on 10/30/2024 01:18 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 HOME		FACILITY NUMBER:	435202536
ADMINISTRATOR/ DIRECTOR:	ZHANG, BIAO		FACILITY TYPE:	740
ADDRESS:	15 DARRYL DRIVE		TELEPHONE:	(408) 418-8188
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	10/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:25 AM
MET WITH:	Licensee, Biao Zhang		TIME VISIT/ INSPECTION COMPLETED:	01:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection visit at 9:25AM and met with Licensee Biao Zhang. LPA toured the facility inside and out with the Licensee to include the resident dining room, kitchen, resident bedrooms, bathrooms, and exterior. Facility temperature maintained at 71 degrees. Facility staff are fingerprint cleared and associated to facility. All emergency exits were observed to be clear of obstruction. LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. Refrigerator temperature maintained at 41 degrees F and freezer maintained at -5 degrees F. LPA measured hot water temperature at 106.3 for kitchen and 2 resident bathrooms. LPA observed medications were in a locked top kitchen cabinet. LPA observed additional medication and sharps in two separate unlocked drawers in the kitchen. LPA advised Licensee that all medications and sharps are to be locked and inaccessible to residents in care. LPA Tarin toured resident bedrooms. 6 out of 6 resident bedrooms had functioning lights, storage space for personal belongings, clean bedding, a chair, lamp and dresser/table. In R3's bedroom (resident room 3), LPA observed medication in an unlocked dresser drawer (picture taken). R3 bedroom is a shared bedroom with R2. The facility was equipped with smoke and carbon monoxide detectors and functioned properly when tested. Fire extinguishers were last serviced on 10/06/2023. LPA observed the facility first aid kit and it was observed to be complete. The facility fire/earthquake drill log was reviewed and drills are being conducted quarterly. The last fire drill was conducted on 08/23/2024. Facility has emergency disaster plan. See LIC809C

Jin Jackie	TELEPHONE: (714) 319-3786
Marcella Tarin	TELEPHONE: (714) 328-5152
	DATE: 10/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

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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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
	VISIT DATE: 10/30/2024

NARRATIVE

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LPA reviewed 6 residents Centrally Stored Medication and Destruction Records (CSMDR). LPA observed 6 out of 6 CSMDRs are complete with all medications accounted and documented. LPA observed the medication storage area was locked and inaccessible to residents in care.

LPA reviewed 6 resident records. LPA observed 5 out of 6 resident records as complete to include a physician's report, TB result, updated appraisal/needs and services plan, identification and emergency contact information, personal rights, and consent forms. Resident (R3) record did not contain an updated physician's report. Resident R3 physician's report was not updated within the year. R3 has neurocognitive disorder. LPA advised Licensee to obtain updated physician's reports for Resident R3.

LPA reviewed 3 staff records. LPA observed 2 out of 3 records to include fingerprint clearance, health screening, TB result, and personnel record. Staff 2's file was not available for review. Licensee states he does not have the documents for S2's file. LPA advised licensee that personnel records shall be available for review by the licensing agency.

Deficiencies were cited today per California Code of Regulations, Title 22. A Technical Violation was also issued. See LIC809-D. Exit interview was conducted with Licensee Biao Zhang. A copy of this report was provided to Licensee and Appeal Rights were provided.

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/30/2024 01:18 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: 10/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed medication and sharps in two separate unlocked drawers in the kitchen which are easily accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/31/2024
	Plan of Correction
1 2 3 4	Licensee states the facility will lock all medications and sharps to ensure they are not accessible to residents in care. Licensee will submit a statement of understanding of the regulation cited. Licensee will submit POC to LPA Tarin by POC due date 10/31/2024.

Type A

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Resident (R3) record did not contain an updated physician's report. Resident R3 physician's report was not updated within the year. R3 has neurocognitive disorder which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/31/2024
	Plan of Correction
1 2 3 4	Licensee states the facility will call R3 family to request and updated physician report. Licensee will submit a statement of understanding of the regulation cited. Licensee will submit POC to LPA Tarin by POC due 10/31/2024.

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: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 10/30/2024 01:18 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: 10/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed medication in an unlocked dresser drawer in R3's bedroom,(R3 has neurocognitive disorder and shares a bedroom with R2). Medication is accesible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/31/2024
	Plan of Correction
1 2 3 4	Licensee stated the medication will be removed from the room and locked, and inaccessible to residents in care. Licensee will submit POC to LPA Tarin by POC due date 10/31/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC809 (FAS) - (06/04)

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