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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803362
Report Date: 04/19/2022
Date Signed: 04/19/2022 02:48:54 PM


Document Has Been Signed on 04/19/2022 02:48 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:VALLEY VIEW CARE HOMEFACILITY NUMBER:
496803362
ADMINISTRATOR:CREDO, JOSEPHINEFACILITY TYPE:
740
ADDRESS:515 MIDDLE RINCON ROADTELEPHONE:
(707) 538-2140
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:6CENSUS: 5DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Josephine CredoTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA), Erik Gonzalez Campos arrived unannounced to conduct a Required - 1 Year inspection at approximately 1:00 PM, and met with licensee/administrator Josephine Credo. The inspection is focused on the Infection Control procedures and practices of this facility. LPA was initially greeted by staff, licensee/administrator arrived shortly.

Upon entry LPA was screened for COVID symptoms and asked to sign in by staff. At primary entrance LPA observed visitor sign-in sheet. LPA conducted walk through of the facility with licensee/administrator and observed COVID postings throughout. Mitigation plan was submitted by licensee and reviewed by Community Care Licensing.

Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Per administrator, updated infection control guidelines and PINs are communicated to responsible parties verbally and through text. Staff have completed Personal Protective Equipment (PPE) and infection control training through Kaiser. Staff have been N95 fit tested. High touch surface areas are disinfected daily. Due to current facility census residents could isolate in their own rooms if they became ill. LPA observed PPE necessary to support a resident in isolation. Residents are screened once a day for symptoms.

Residents' emergency contact information has been updated and administrator confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible to residents. Medications are centrally stored and inaccessible to residents. Facility is not currently conducting COVID-19 surveillance testing. All residents have received their booster shot. All staff have received their booster shot.

Continued on LIC 809C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: VALLEY VIEW CARE HOME
FACILITY NUMBER: 496803362
VISIT DATE: 04/19/2022
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Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. Common areas are also set up for social distancing.

LPA requested the following documents during the visit:

LIC 500
LIC 308
LIC 9020
Liability Insurance
Emergency Disaster Plan
Administrator Certificate

No deficiencies cited during this inspection.

Exit interview conducted with Licensee/Administrator, Josephine Credo. A copy of this report was printed for the facility.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC809 (FAS) - (06/04)
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