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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202587
Report Date: 02/14/2025
Date Signed: 02/14/2025 11:26:00 AM

Document Has Been Signed on 02/14/2025 11:26 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:GREEN VALLEY RESIDENTIAL CARE HOMEFACILITY NUMBER:
435202587
ADMINISTRATOR/
DIRECTOR:		SEDIGH, TAYEBEHFACILITY TYPE:
735
ADDRESS:10512 DUKE DRIVETELEPHONE:
(408) 841-3992
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 4DATE:
02/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Tayebeh SedighTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct the facility's annual required - 1 year inspection. LPA met with Administrator, Tayebeh Sedigh.

During visit, LPA toured the facility with the staff to include the activity rooms, kitchen, dining room, living room, laundry room, garage, 3 resident bedrooms, 2 staff bedrooms, bathrooms, and exterior. There were no residents present in the facility. All staff present are fingerprint cleared and associated to the facility.

LPA observed the facility sketch does not match the actual purpose of the rooms in the facility. LPA observed the staff room to the left of the main entrance is now being used as an activity room, the recreation room next to the right of the main entrance is now being used as a staff room, and the staff room at the end of the hall to the right of the facility is now being used as a recreation room. Administrator had an updated copy of the facility sketch that the Department did not receive. Administrator was advised to make adjustments and submit an updated facility sketch to match the physical plant.

The facility has an empty pool that is fully fenced, The fence is at least 5 ft high. Facility temperature maintained between 64 - 68 degrees F. Fire place observed screened in the living room. Activities calendar posted. Chemicals, disinfectants, toxins, and medications observed locked. Facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperature maintained at 2 degrees C and freezer temperature maintained at -18 degrees C. Sharp objects observed locked.
See LIC809-C.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2025
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: 02/14/2025
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3 resident bedrooms observed to include beds, linens, adequate lighting, night stands, dresser, and closet. All bedrooms contains an exit door which was observed free and clear of obstruction. 1 out of 4 resident beds observed with a half bed rail. Based on record review, there was no physician's order on file. Administrator was advised to obtain a physician's order for the half rails.

Bathroom hot water temperature next to bedroom #3 maintained at 117.5 degrees F. Bathrooms contains grab bars by the toilet and next to the shower.

3 resident files were reviewed and observed complete and no issues noted. 3 resident's centrally stored medication and records were reviewed and all medications were accounted for, no issues noted. 3 resident's P&I money was reviewed with the Administrator and all money was accounted for, no issues noted.

Based on record review, 2 out of 4 residents are over the age of 60. Administrator plans to submit an exception request for the 2 residents. Administrator was provided a list of documents to submit to Licensing for the exception requests and advised to review Title 22 Section 85068.4.

3 staff files were reviewed and observed complete. Staff are provided annual training. 1 out of 3 staff has an updated first aid certificate.

Facility has an infection control plan. Staff are provided training on infection control. Fire drills are being completed quarterly, the last drill was completed in January 2025. Facility has flashlights and extra batteries in case of an emergency. The facility has "go-bags" that contains emergency supplies.

During visit, the following documents were obtained to include the LIC500, LIC200, and LIC308.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory note provided. This report was reviewed with Administrator, Tayebeh Sedigh and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025
LIC809 (FAS) - (06/04)
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