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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202536
Report Date: 11/08/2024
Date Signed: 11/08/2024 10:43:46 AM

Document Has Been Signed on 11/08/2024 10:43 AM - 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/
DIRECTOR:		ZHANG, BIAOFACILITY TYPE:
740
ADDRESS:15 DARRYL DRIVETELEPHONE:
(408) 418-8188
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: 6CENSUS: 6DATE:
11/08/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Administrator, Biao ZhangTIME VISIT/
INSPECTION COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conducted a case management to follow up on deficiencies that were cited on 10/30/2024. LPA met with Administrator (ADM) Biao Zhang.

During the annual inspection on 10/30/2024, LPA Tarin observed medication and sharps in two separate unlocked drawers in the kitchen. During tour of resident rooms, LPA Tarin observed in R3's bedroom (resident room #3), medication in an unlocked dresser drawer. R3 has neurocognitive disorder and shares a bedroom with R2. R3 did not have an updated physician's report during visit. Deficiencies were issued for unlocked sharp and medication, and for R3 not having an updated physician's report (R3 has neurocognitive disorder).

During today's visit, LPA Tarin toured the kitchen. LPA Tarin observed all kitchen drawers free of sharps and medication. LPA Tarin observed medication and sharps in a locked kitchen cabinet (above countertop, near kitchen sink).

LPA toured R3's bedroom and observed no medication in unlocked dresser drawer. ADM stated medication has been moved to a locked cabinet in the kitchen. LPA Tarin observed medication in a locked kitchen cabinet, inaccessible to residents. LPA Tarin toured 4 additional resident room and checked dresser drawers and observed no medications in the dresser drawers.

ADM provided LPA Tarin with documentation for R3's updated physician's report. ADM states R3 had an assessment with his/her physician on 11/7/2024, and is awaiting the updated physician report. ADM states the facility will submit a copy of the physician's report to LPA Tarin once it is received.

See LIC 809C
SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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: 11/08/2024
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LPA Tarin cleared the deficiencies cited on 10/30/2024 during today's visit. A Letter of Deficiency Citations Cleared was printed and provided to ADM during today's visit.

No deficiency was cited per California Code of Regulations, Title 22.

This report was reviewed with Administrator, Biao Zhang and a copy of the report was provided.
SUPERVISORS NAME: Jin Jackie
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
LIC809 (FAS) - (06/04)
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