496803362-6-1-2023-21-AS-FSAI-CSDVJF-20230601162840

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803362
Report Date: 06/01/2023
Date Signed: 06/01/2023 04:28:45 PM

Document Has Been Signed on 06/01/2023 04:28 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 HOME		FACILITY NUMBER:	496803362
ADMINISTRATOR:	CREDO, JOSEPHINE		FACILITY TYPE:	740
ADDRESS:	515 MIDDLE RINCON ROAD		TELEPHONE:	(707) 538-2140
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95409
CAPACITY:	6	CENSUS: 4	DATE:	06/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Caregiver, Imelda Valdez Administrator, Josephine Credo		TIME COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Valley View Care Home for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Caregiver, Imelda Valdez, and was granted access into the facility. Administrator, Josephine Credo arrived 30 minutes later. LPA toured the facility. LPA found the facility to be clean and at a comfortable temperature with all exits free from obstruction. Hygiene products and linens were available and required bath mats and grab bars were observed. Water temperature in resident's bathrooms measured at 110 degrees in 2 out of 2 bathrooms and is within an acceptable range of 105 to 120 degrees F. Fire Extinguisher was last charged on February 2023. First Aid Kit was inspected and found to be appropriate during the inspection. Cleaning products and other toxins are located in a locked cabinet in the laundry room. Knives are located in a locked drawer in the kitchen. Perishable and non-perishable foods were sufficient, with a 2-day supply of perishable foods, and a 7-day supply of non-perishable foods, as required. Medications were centrally stored and locked during the inspection. 4 out of 4 Medication logs for residents in placement were reviewed and found to be appropriate during the inspection. Smoke detectors located throughout the facility and carbon monoxide detector were tested and were operational during the inspection. All doors have auditory alert system that alert staff. Food menu was presently available for viewing during the inspection. Cleaning products and other toxins are located in the laundry room that was locked and inaccessible to residents in care. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms in resident’s rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of all resident bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. (Report continued on LIC 809C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VALLEY VIEW CARE HOME	FACILITY NUMBER: 496803362
	VISIT DATE: 06/01/2023

NARRATIVE

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LPA and Licensee reviewed the Infection Control Plan for the facility. LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. During a review of the COVID-19 Infection Control Plan, LPA observed the facility did not have Decontamination Procedures as outlined in Title 22 regulation (See LIC 9102-Technical Advisory). During a brief review of the Emergency Disaster Drill, LPA learned that the facility has not had an Emergency Disaster Drill as outlined in Title 22 regulations (See LIC 809D).

File reviews were conducted. 4 of 4 resident files were reviewed during the Required 1 year inspection. However, during the review of the resident files, 4 out of 4 Care Plans were not observed (See LIC 9102-Technical Assistance). LPA conducted resident interviews during this Required 1 year inspection. 3 of 3 staff files were reviewed. Staff interviews were conducted during the Required 1 year inspection. During the staff file review, LPA observed 2 out of 3 staff members are do not have sufficient hours of training as outlined in Health and Safety Code 1569.625 (b)(2) (See LIC 9102-Technical Violation).

LPA requested the following documents to be sent:

LIC 500- Personnel Report
Most up-to-date Liability insurance
Control of Property
Register of residents

The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and a copy of this report along with appeal rights were given to the Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/01/2023 04:28 PM - 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
CCLD Regional Office, 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: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on an interview with the Administrator and Record Review, the licensee did not comply with the section cited above in which the facility did not conduct a drill at least quarterly for each shift which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/08/2023
	Plan of Correction
1 2 3 4	Plan of Correction shall include a statement regarding future compliance. In addition, Licensee shall fill out at LIC 9098 Self-Certification form reading and understanding the regulation as it relates to conducting quarterly drills and retaining the record of the drills that are conducted.

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: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC809 (FAS) - (06/04)

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