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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202587
Report Date: 02/06/2024
Date Signed: 02/06/2024 03:51:42 PM

Document Has Been Signed on 02/06/2024 03:51 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:GREEN VALLEY RESIDENTIAL CARE HOMEFACILITY NUMBER:
435202587
ADMINISTRATOR:SEDIGH, TAYEBEHFACILITY TYPE:
735
ADDRESS:10512 DUKE DRIVETELEPHONE:
(408) 841-3992
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 6DATE:
02/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Tayebeh SedighTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual required - 1 year inspection. LPA met with Administrator (ADM), Tayebeh Sedigh.

During visit, LPA toured the facility with the ADM to include the the entrance, resident bedrooms, bathrooms, staff room, kitchen, living room, garage, and exterior. All fire exit routes were free and clear of obstruction. Fire extinguisher last serviced on 03/23/2023. LPA observed a carbon monoxide detector located in the hallway.

The facility has a pool that contains a fence that is at least 5 ft high and does not contain water. Facility temperature maintained at 60 degrees and 66 degrees Fahrenheit. There was 1 resident present in the facility. The Administrator turned on the heater and LPA observed the facility temperature maintained at 68 degrees Fahrenheit before end of visit. Fire place observed screened in the living room.

Resident bedrooms observed well maintained. Bedrooms equipped with beds, linens, dressers and adequate lighting. All exit routes were free and clear of obstruction. Bathroom hot water maintained at 118 degrees Fahrenheit. Bathroom supplied with lidded trash bins, paper supplies, and hot water temperature. Shower contains a non-slid mat. Facility has an adequate supply of hygiene products and linens.

The facility has at least 2 days worth of perishables and 7 days worth of non-perishables. Refrigerator temperature maintained at 2 degrees Celsius and freezer temperature maintained at -18 degrees Celsius. Chemicals, disinfectants, and sharp objects observed locked.

SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2024
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: GREEN VALLEY RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202587
VISIT DATE: 02/06/2024
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LPA reviewed 3 resident files to include a medical assessment, TB result, consent forms, ID and emergency information, safeguard of personal properties and valuables, and personal rights form. LPA reviewed 3 residents P&I money, centrally stored medications and centrally stored medication records were maintained.

LPA reviewed 3 staff files to include a 1st aid certification, LIC501, LIC503, and TB result. Staff are fingerprint cleared and associated to the facility. LPA reviewed the staff's annual training documents.

Facility has an infection control plan. Staff are provided training on infection control. Facility has an isolation room. LPA observed a PPE cart with PPE supplies and COVID-19 related poster next to the isolation room. The isolation room contains a bed and other storage items.

Facility has an emergency disaster plan posted at the entrance. Facility has flashlights and extra batteries. The facility has "go-bags" that contains emergency supplies. LPA advised ADM to go through the "go-bags" to ensure the items inside the bags are not expired. ADM stated understanding. LPA observed the facility conducts emergency drills quarterly. The last drill was conducted on 02/02/2024.

LPA interviewed 3 staff members.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator (ADM), Tayebeh Sedigh and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2024
LIC809 (FAS) - (06/04)
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