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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803362
Report Date: 07/19/2024
Date Signed: 07/19/2024 03:15:39 PM


Document Has Been Signed on 07/19/2024 03:15 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
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: 6DATE:
07/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Josephine CredoTIME COMPLETED:
03:30 PM
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At approximately 2:50pm Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management and was greeted by caregiver. Licensee Josephine Credo contacted by phone and gave caregiver permission to sign report. LPA advised Admin of the nature of the visit as being to re-cited for outstanding deficiencies. Facility currently has 6 residents in care, one of which is on hospice, which is allowable per the facility's Hospice Waiver.

On 5/22/2024 LPA conducted the required annual inspection for this facility. The inspection resulted in 9 citations for the following respective deficiencies: HSC1569.618(c)(3), 87303(a), 87303(e)(5), 87463(c), 87705(c)(5), 87405(a), 87412(a)(11), 87465(a)(4), and 87412(c). Each deficiency had its own respective plan of correction due date. The plans of correction for deficiencies HSC1569.618(c)(3), 87303(a), and 87303(e)(5) have been fulfilled. However, the plans of correction for the deficiencies (87463(c), 87705(c)(5), 87405(a), 87412(a)(11), 87465(a)(4), and 87412(c)) are still outstanding.

On 5/23/2024 licensee emailed LPA to ask for an extension on plan of correction due dates. LPA granted the extension request and advised the following: Please do not worry about the plans due in order to satisfy the plan of correction due date today. Please submit them by Tuesday, 5/28/24. And, remember that only the plan to get the staff 1st Aid/CPR certified is due, not the actual certifications. The actual certifications are not due until 6/5/24. Same goes for the medication training. Only the plan was due today (now due 5/28/2024) and the actual training does not have to be completed until 6/12/2024.

On 6/11/2024 licensee emailed LPA to ask for another plan of correction due date extension, LPA once again granted an extension and advised via email: In regard to the currently past due plans of correction, CCL is extending the due date to this Friday, 6/14/24 in order for you to gather all the necessary items and submit them.

Continued on 809C...

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024
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: 07/19/2024
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Continued from 809...

CCL granted licensee plan of correction due date extensions on two different occasions. However, the plans of correction for deficiencies 87463(c), 87705(c)(5), 87405(a), 87412(a)(11), 87465(a)(4), and 87412(c)) are still outstanding. Therefore, the deficiencies issued on 5/22/2024 that remain outstanding are being re-cited (deficiencies cited, see 809Ds).

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 caregiver. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with caregiver 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: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/19/2024 03:15 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
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: 07/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2024
Section Cited
CCR
87465(a)

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87465 (a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: 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
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Facility to submit plan to train staff on how to properly administer medication to residents by plan of correction due date of 7/22/2024. Training materials to be submitted to CCL for approval. Training logs to contain name of trainer, (continued below)
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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
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(continued from above)
name of course, duration of course in hours, dated completed and employee attendee. Training to be completed no later than 7/26/2024
Type A
07/22/2024
Section Cited
CCR87405(a)

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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: Based on LPA and Admin observation and record review, the licensee did not comply with the
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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 7/22/2024
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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 immediate health, safety or personal rights risk to persons in care.
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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: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/19/2024 03:15 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
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: 07/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2024
Section Cited
CCR
87412(c)

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87412 (c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
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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 (continued below)
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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 S3, S4, and S5 did not have Training records available, which poses an immediate health, safety or personal rights risk to persons in care.
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(continued form above)
employee attendee name. Training to be completed no later than plan of correction due date 7/26/2024
Type B
07/26/2024
Section Cited
CCR87412(a)

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87412(a) The licensee shall ensure that personnel records are maintained... 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:
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Facility to submit pictures of completed Health Screens for S2, S4, and S5 by plan of correction due date of 7/26/2024
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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 S2, S4, and S5 did not have Heath Screens, which poses an potential health, safety or personal rights risk to persons in care.
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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: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/19/2024 03:15 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
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: 07/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2024
Section Cited
CCR
87463(c)

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87463 (c) The licensee shall arrange a meeting with the resident, the resident's representative.. 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.
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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 of 7/26/2024
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This requirement is not met as evidenced by: 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.
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Type B
07/26/2024
Section Cited
CCR87705(c)

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87705(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...This requirement is not met as evidenced by: Based on LPA and Admin observation
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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 of 7/26/2024
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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.
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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: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024
LIC809 (FAS) - (06/04)
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