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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803362
Report Date: 05/22/2024
Date Signed: 05/29/2024 10:32:58 AM


Document Has Been Signed on 05/29/2024 10:32 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
SANTA ROSA RO, 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:
05/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Josephine Credo, AdministratorTIME COMPLETED:
04:34 PM
NARRATIVE
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Licensing Program Analysts (LPA) Christi Coppo and Jacqueline Macias arrived unannounced to conduct a required Annual inspection and was greeted by Caregiver. Administrator, Josephine Credo arrived later. Facility contact information was reviewed.

At approximately 9:30am LPAs and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPAs observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was mostly found to be stored in a safe manner with open items covered: one bottle of Tapatio sauce expired 04/2024, one bottle of sesame oil expired as of 9/18/2022, and opened jar of sardines stored at room temperature in cabinet. LPAs advised caregiver that directions on jar of sardines state to refrigerate after opening. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked. Hole in the kitchen wall by outlet near door exiting to the backyard.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean, bedroom #2 had a soft spot underneath wood flooring, when pressed upon with weight, floor gives way and sinks in (deficiency cited, see 809D). Extra hygiene products and linens were available. Resident bathroom next to laundry room had non-skid mat present but mat had black spots and film underneath mat (deficiency cited, see 809D). Both bathrooms in main hallway had required grab bars. Water temperature in sink accessible to residents in care measured at 110.7 and 106 degrees F which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 2/19/2024. Smoke/Carbon Monoxide detectors located throughout the facility. Facility’s last quarterly disaster drills were conducted on January 25, 2024. Facility has a backup generator for use during a power outage.

Continued on 809C...
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: VALLEY VIEW CARE HOME
FACILITY NUMBER: 496803362
VISIT DATE: 05/22/2024
NARRATIVE
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Continued from 809...

At approximately 11:00am LPAs conducted a review of 5 resident records. R1, R2, and R5 have diagnosis of Dementia but their Physicians Reports are dated 2022 (deficiency cited, see 809D). R1, R2, and R5 did not have any Appraisal Needs and Services Plan (R5 had plan present but not dated at the top of appraisal -note says to see 602, 602 dated 2022) (deficiency cited, see 809D).

At approximately 12:30am LPAs conducted review of 5 staff records. S1, S2, S3, S4, and S5 did not have current First Aid/CPR (deficiency cited, see 809D). S2, S4, and S5 did not have Heath Screen (deficiency cited, see 809D). S3, S4, and S5 did not have Training records available (deficiency cited, see 809D).

At approximately 2:00pm LPAs and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet in office. LPAs and Administrator observed medication errors during spot check of R2s medication: Vitamin B12 bubble pack with start date of 5/15/2024 had one tablet missing. Levothyroxine with start date of 5/15/2024 had one tablet missing (deficiency cited, see 809D).

Josephine Credo, Administrator could not provide a copy of current Administrator Certificate or provide copy of email indicating receipt of renewal payment from CCL (deficiency cited, see 809D).. Facility licensing fees due, LPAs gave caregiver LIS printout with PIN and amount due.



. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report, LIC308- Designation of Responsibility, and Liability Insurance.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/29/2024 10:32 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: VALLEY VIEW CARE HOME
FACILITY NUMBER: 496803362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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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2
3
4
Based on LPA and Admin observation, the licensee did not comply with the section cited above in that bedroom #2 had a soft spot underneath wood flooring, when pressed upon with weight, floor gives way and sinks in and there is a hole in the kitchen wall by outlet near door exiting to the backyard, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2024
Plan of Correction
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2
3
4
Facility to submit pictures of repairs along with LIC9098 self-certifying repairs have been completed by plan of correction due date.
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation the licensee did not comply with the section cited above in that the resident bathroom next to laundry room had non-skid mat present but mat had black spots and film underneath mat, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
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Facility to submit pictures of non-skid mat present in resident bathroom next to laundry room free from black film and/or spots by plan of correction due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
LIC809 (FAS) - (06/04)
Page: 3 of 10


Document Has Been Signed on 05/29/2024 10:33 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: VALLEY VIEW CARE HOME
FACILITY NUMBER: 496803362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
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Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that R1, R2, and R5 did not have any Appraisal Needs and Services Plan (R5 had plan present but not dated at the top of appraisal -note says to see 602, 602 dated 2022), which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2024
Plan of Correction
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Facility to submit pictures to CCL of current Appraisal, Needs, and Services Plans for R1, R2, and R5 by plan of correction due date.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that R1, R2, and R5 have diagnosis of Dementia but their Physician's Reports are dated 2022 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2024
Plan of Correction
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Facility to submit pictures to CCL of current Physician's Report for R1, R2, and R5 by plan of correction due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/29/2024 10:33 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: VALLEY VIEW CARE HOME
FACILITY NUMBER: 496803362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(a)
87405 Administrator - Qualifications and Duties 87405 (a) All facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that Josephine Credo, Administrator could not provide a copy of current Administrator Certificate or provide copy of email indicating receipt of renewal payment from CCL, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
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Admin to submit picture of email and/or letter indicating receipt of renewal payment for Administrator Certificate from CCL or picture of current Administrator Certificate by plan of correction due date.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/29/2024 10:33 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: VALLEY VIEW CARE HOME
FACILITY NUMBER: 496803362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
87412(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S2, S4, and S5 did not have Heath Screens, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2024
Plan of Correction
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2
3
4
Facility to submit pictures of completed Health Screens for S2, S4, and S5 plan of correction due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/29/2024 10:33 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: VALLEY VIEW CARE HOME
FACILITY NUMBER: 496803362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
87465 (a)(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that LPA and Admin observed medication errors during spot check of R2s medication: Vitamin B12 bubble pack with start date of 5/15/2024 had one tablet missing. Levothyroxine with start date of 5/15/2024 had one tablet missing which poses an immediate health, safety or personal rights risk to persons in care
POC Due Date: 05/23/2024
Plan of Correction
1
2
3
4
Facility to submit plan to train staff on how to properly adminsiter medication to residents by plan of correction due date of 5/23/2024. Training materials to be submitted to CCL for approval. Training logs to contain name of trainer, name of course, duration of course in hours, dated completed and employee attendee. Training to be completed no later than 6/12/2024
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/29/2024 10:33 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: VALLEY VIEW CARE HOME
FACILITY NUMBER: 496803362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)
87412 (c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S3, S4, and S5 did not have Training records available, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2024
Plan of Correction
1
2
3
4
Facility to submit pictures of completed training logs for S3, S4, and S5 by plan of correction due date. Training materials to be submitted to CCL for approval. Training logs to contain name of trainer, name of course, duration of course in hours, dated completed and employee attendee.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/29/2024 10:33 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: VALLEY VIEW CARE HOME
FACILITY NUMBER: 496803362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
HSC 1569.618(c)(3)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S1, S2, S3, S4, and S5 did not have current First Aid/CPR, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2024
Plan of Correction
1
2
3
4
Facility to submit plan to have S1, S2, S3, S4, and S5 obtain First Aid/CPR certification. Certification to be completed for all identified staff no later than 6/5/2024
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
LIC809 (FAS) - (06/04)
Page: 9 of 10