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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202536
Report Date: 10/09/2025
Date Signed: 10/09/2025 05:27:28 PM

Document Has Been Signed on 10/09/2025 05:27 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/
DIRECTOR:		ZHANG, BIAOFACILITY TYPE:
740
ADDRESS:15 DARRYL DRIVETELEPHONE:
(408) 418-8188
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: 6CENSUS: 6DATE:
10/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Licensee Biao ZhangTIME VISIT/
INSPECTION COMPLETED:
05:35 PM
NARRATIVE
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Licensing Program Analysts (LPA) Marcella Tarin and Manuel Monter conducted an unannounced annual inspection and to follow up on a resident elopement that occurred in March 2025. LPAs met with Licensee Biao Zhang. LPAs stated the purpose of the visit.

LPAs toured the interior and exterior of the facility with Licensee to include the kitchen, resident rooms, dining room, bathrooms, back and front of the facility. During tour of the interior and exterior of the facility, LPAs observed spiderwebs around residents windows, dirt on residents interior windows,a ripped and torn couch in living room, brown stains on walls through the facility.

LPAs also observed two office rooms being used as a resident and staff room. LPAs observed a bed and personal belongs in each 'office' room. LPAs observed medication bottles in 'family room', accessible to residents.

During inspection of the backyard facility, LPAs observed a gate that had a lock. Licensee states some residents are not allowed to exit the facility. During visit, Licensee removed the lock from the gate. LPAs observed all other exits and passageways to be free and clear of obstruction.

LPAs 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. LPA measured refrigerator temperature at 35 degrees F and Freezer at 0 degrees F.

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NAME OF LICENSING PROGRAM MANAGER: Jin Jackie
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2025
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 10
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 10
Document Has Been Signed on 10/09/2025 05:27 PM - It Cannot Be Edited


Created By: Marcella Tarin On 10/09/2025 at 03:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPAs observed two 'office rooms' being use a resident rooms, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2025
Plan of Correction
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Licensee states he will submit an updated facility sketch to request an updated fire inspection to CCLD by POC due date 10/10/2025.
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPAs observed spiderwebs around residents windows, dirt on residents interior windows, ripped and torn couch in living room, brown stains on walls through the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2025
Plan of Correction
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Licensee states he clean the areas mentioned, and ensure the faciliyt is clean, safe and sanitary for all residents. Licensee states he will submit the POC to CCLD by POC due date 10/10/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jin Jackie
NAME OF LICENSING PROGRAM MANAGER:
Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2025


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 10/09/2025 05:27 PM - It Cannot Be Edited


Created By: Marcella Tarin On 10/09/2025 at 03:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, LPAs observed a gate with a lock on the side of the facility, which poses an immediate health, safety or personal rights risk to persons in care. Licensee removed lock during inspection visit.
POC Due Date: 10/10/2025
Plan of Correction
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Licensee removed the lock from gate on the side of the facility. Licensee will submit a statement of understanding of the regulation cited.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPAs observed medications on a dresser in R2s bedroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2025
Plan of Correction
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Licensee states he will ensure that residents do not keep medications in their room.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jin Jackie
NAME OF LICENSING PROGRAM MANAGER:
Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2025


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 10/09/2025 05:27 PM - It Cannot Be Edited


Created By: Marcella Tarin On 10/09/2025 at 03:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, 1 Out of 2 staff (S2) did not have training for 2025, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2025
Plan of Correction
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Licensee states he will submit a plan of action stating how S2 will complete required 20 hours of training. Licensee stated he will submit documentation of S2's completion of training to CCLD. Licensee will submit POC by POC due date 10/10/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Jin Jackie
NAME OF LICENSING PROGRAM MANAGER:
Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2025


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 10/09/2025 05:27 PM - It Cannot Be Edited


Created By: Marcella Tarin On 10/09/2025 at 03:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(16)
Resident Records
(b) Each resident's record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, 3 Out of 3 resident records did not contain personal property log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2025
Plan of Correction
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Licensee states he will have residents completed the Safeguard for Resident Cash, Personal Property and Valuables and place in their file. Licensee will submit POC to CCLD by POC due date of 10/16/2025.
Type B
Section Cited
CCR
87456(a)(3)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, 3 Out of 3 resident records did not contain an updated medical assessment/physicians report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2025
Plan of Correction
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Licensee states he will call each resident's responsible parties to obtain an updated physician's report. Licensee will submit POC to CCLD by POC due date 10/16/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jin Jackie
NAME OF LICENSING PROGRAM MANAGER:
Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2025


LIC809 (FAS) - (06/04)
Page: 6 of 10
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: 10/09/2025
NARRATIVE
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LPAs observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care.

The facility was equipped with smoke and carbon monoxide detectors. All smoke detectors functioned properly when tested by Licensee. Fire extinguishers were last serviced on 2/11/2025. The facility emergency drill log was reviewed. The facility's last drill was on 9/18/2025.

LPAs toured 6 resident bedrooms. All 6 resident rooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. During inspection of R2's, LPAs observed pills in a cup on R2's dresser. Based on review of R2's physician's report, R2 cannot store or administer his/her own medications.

LPAs toured 2 bathrooms. All 2 bathrooms had hand soap, paper towels, functioning lights, and covered trash bins. LPAs measured water temperature with a range of 109 F to 111.5 F.

LPAs reviewed 3 resident records. All 3 resident records did not have an updated physician's report, updated service plan, and did not contain personal property log.

LPAs reviewed 3 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s).

LPAs reviewed 2 staff records. 1 Out of 2 staff records did not have training for 2025. Licensee provided LPAs with a training document for S2 with dated 2025. Upon further review, LPAs observed a handwritten 2025 over the 2024 dates. Licensee stated S2 did not have training for 2025 and apologized for writing 2025 over the 2024 training dates.

Elopement incident

On April 1, 2025, the Department received an incident Report regarding resident R1. The incident Report stated, on March 29, 2025, resident R1 was missing. R1 was last seen on 3/28/2025, at 11:45pm, by another resident. The incident report states, the facility contacted Campbell police. The incident report states "Based on the surveillance camera record, there was a movement when the sensor light went on at 4:52AM on 3/29/2025"


Page 2 of 3
NAME OF LICENSING PROGRAM MANAGER: Jin Jackie
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC809 (FAS) - (06/04)
Page: 7 of 10
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: 10/09/2025
NARRATIVE
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**This is an amended report to issue the correct citation and civil penalty for an elopement**
On April 1, 2025, LPA Tarin interviewed Licensee Zhang. Licensee stated, R1 was found on 3/31/2025 and they do not know where R1 was found. Licensee states he heard from R1's responsible party that R1 was found on Stevens Creek Blvd near a gas station, but does not know the condition of R1. Licensee states R1 was last seen on facility surveillance on 3/29/2025 at 7:21AM.

On March 29, 2025, Local Law enforcement, at approximately 8:07am, responded to a missing person report, regarding R1. It was reported that R1 was last seen in his/her room at 8:30pm the previous night. When checked approximately 30 minutes later, R1 was no longer there. On March 29, 2025, at approximately 7:30am, it reported that R1 was missing from his/her room.

On April 1, 2025, at approximately 4:32pm, local law enforcement was informed R1 was found at Stevens Creek Blvd and Cypress Ave.

The Department reviewed R1’s physician’s report dated September 8, 2023, which states R1 is not able to leave the facility unassisted.

Based on a Google Maps Review, the location R1 was found was 2.9 miles from the facility, without staff supervision.

As a result, an immediate civil penalty of $500.00 is being assessed Section 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities, against the facility today for violation for absence of supervision, which resulted in R1 eloping from the facility. The deficiency and civil penalty are assessed on a case management visit on 12/26/2025. See LIC809 for 12/26/2025.

Licensee stated he would not sign the report because it was related to the elopement and civil penalty assessed. Licensee stated he was refusing to sign the report unless LPAs removed the civil penalty. LPA Tarin stated to Licensee the civil penalty would not be removed.

Deficiencies are being cited during today's visit per California Code of Regulations Title 22. An exit interview was conducted with Licensee Biao Zhang and a signed copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2025
LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 10/09/2025 05:27 PM - It Cannot Be Edited


Created By: Marcella Tarin On 10/09/2025 at 04:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
87468.1(a)(2)
87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above. Resident R1 eloped from the facility on 3/29/2025. R1 is unable to leave the facility unassisted which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2025
Plan of Correction
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3
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Licensee states he will submit a plan to address R1's elopement behavior to CCLD by POC due date by 10/10/2025.
Type A
Section Cited
CCR
87405(d)(2)
87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the totality of today's visit, Licensee did not confirm to rules and regulations by ensuring R1 did not elope, R1's care plan was not updated, resident medication was accessible. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2025
Plan of Correction
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2
3
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Licensee states he will send a letter that he understand his duties and responsibilities of Administrator, and that he will be in compliance moving forward. Licensee will submit POC to CCLD by POC due date of 10/10/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jin Jackie
NAME OF LICENSING PROGRAM MANAGER:
Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2025


LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 10/09/2025 05:27 PM - It Cannot Be Edited


Created By: Marcella Tarin On 10/09/2025 at 05:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed


This requirement is not met as evidenced by:
Deficient Practice Statement
1
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3
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Based on observation and interview the licensee did not comply with the section cited above. LPAs observed medication bottles in a box in the 'family room' of the facility, accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2025
Plan of Correction
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Licensee states he will dispose of the medication by taking it to the pharmacy for destruction. Licensee states he will submit the POC to CCLD by POC due date of 10/10/2025
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Jin Jackie
NAME OF LICENSING PROGRAM MANAGER:
Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2025


LIC809 (FAS) - (06/04)
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