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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803362
Report Date: 06/04/2026
Date Signed: 06/04/2026 03:48:52 PM

Document Has Been Signed on 06/04/2026 03:48 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:VALLEY VIEW CARE HOMEFACILITY NUMBER:
496803362
ADMINISTRATOR/
DIRECTOR:		CREDO, ELENAFACILITY TYPE:
740
ADDRESS:515 MIDDLE RINCON ROADTELEPHONE:
(707) 538-2140
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 6CENSUS: 3DATE:
06/04/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Licensee, Josephine CredoTIME VISIT/
INSPECTION COMPLETED:
04:02 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Licensee Josephine Credo. Facility currently has three (3) residents, two (2) of which are on hospice.

At approximately 9:30am LPA toured the building and grounds. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and most were labeled. Cleaning supplies were locked in the laundry room. Kitchen drawer with sharp knives locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 112.3 degrees F which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 2/16/26. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drill was conducted last conducted 3/28/26. Facility has a backup generator for use during a power outage. Facility has large pile, approximately 4 feet tall, of dried leaves, branches, and elements of tree that was cut down. Per licensee, tree was just cut down this weekend and all brush will be removed by 6/11/26.

At approximately 11:30am LPA initiated file review. LPA conducted a review of three (3) resident records. Resident (R1) in room #2 is bedridden and on hospice. However, licensee could not show documentation of notification to fire department (deficiency cited, see 809D). Resident (R2) did not have TB clearance on file.

Continued on 809C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 06/04/2026
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Continued from 809...

R2's 2022 physician's report indicates a PPD test was completed but noted the results are attached on a separate report. Licensee could not produce report showing clearance. The "no evidence of communicable disease" box was checked in ink but did not have a date or any results. R2 also did not have a current physician's report on file, the most current was dated 3/6/25. However, licensee produced an email from R2's hospice nurse stating they and licensee filled out the physician's report and emailed doctor asking doctor to sign it. LPA observed report to be signed and dated with today's date, sent at 11:02am. LPA advised licensee to obtain copy of report with findings as the doctor's notation indicates. LPA reviewed hospice care plans for all residents on hospice. LPA and licensee discussed ensuring physician reports are completed annually. Two (2) out of three (3) residents require use of a hoyer, one of which requires two people to manage incontinence care. However, licensee staffs one person at night. This staff is live-in and is sleeping.

At approximately 1:30pm LPA conducted review of three [3] staff records. Staff (S1) has not been employed at the facility for longer than 12 months, but has only completed eleven (11) hours of the required twelve (12) hours of dementia care training. LPA discussed with licensee ensuring all hours are completed. Facility emplys three (3) staff; two of which completed shadowing training with the newest staff. LPA discussed qualifications required of those conducting training per Health and Safety Code 1569.69

At approximately 2:30pm LPA, caregiver, and licensee conducted a spot check of medication and medication records. Resident (R3) had Docusate Sodium 100mg and Senna 8.6mg medications but there was not a corresponding signed doctor's order on file. R2 had current doctor's orders on file as part of hospice care plan. Discrepancies were identified as to dosing hours and mg/ml of medications. Medication with discrepancies include morphine, lorazapam, haloperidol, and acetaminophen. Medications have not been started yet as they are comfort medications. Licensee will immediately contact pharmacy and hospice prescriber to clarify discrepancies. Additionally, medication counts off by one tablet for all of R2's medications as facility is prepouring for the day. Licensee and caregiver claim LPA advised last year that they could prepour for the day, only. LPA advised of regulation 87465(h)(5). Licensee and caregiver confirmed

Continued on 809C(2)...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
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: 06/04/2026
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Continued from 809C...

they understand facility must cease prepouring medications.

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
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 licensee and a copy of this report was given.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/04/2026 03:48 PM - It Cannot Be Edited


Created By: Christi Coppo On 06/04/2026 at 03:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on LPA and licensee record review, the licensee did not comply with the section cited above in that resident (R3) had Docusate Sodium 100mg and Senna 8.6mg medications but there was not a corresponding signed doctor's order on file, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2026
Plan of Correction
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Facility to submit plan to conduct medication management training with all staff administering medication by plan of correction due date. Training logs to be submitted to CCL by no later than 6/11/26.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/04/2026 03:48 PM - It Cannot Be Edited


Created By: Christi Coppo On 06/04/2026 at 03:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.72(f)
Levels of Care
(f) Notwithstanding the length of stay of a bedridden resident, every facility admitting or retaining a bedridden resident, as defined in this section, shall, within 48 hours of the resident’s admission or retention in the facility, notify the local fire authority with jurisdiction in the bedridden resident’s location of the estimated length of time the resident will retain his or her bedridden status in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and licensee observation, interview, and record review, the licensee did not comply with the section cited above in that Resident (R1) in room #2 is bedridden and on hospice. However, licensee could not show documentation of notification to fire departmen, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/11/2026
Plan of Correction
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Facility to submit to CCL proof of notification to fire dept of bedridden resident in rm#2 by plan of correction due date. If fax is provided as proof of notification, facility to submit along with fax the fax transmission page showing successful transmission.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2026


LIC809 (FAS) - (06/04)
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