502701379-3-27-2026-27-AS-NWPN-DSKS7J-20260327133737

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701379
Report Date: 03/27/2026
Date Signed: 03/27/2026 01:38:18 PM

Document Has Been Signed on 03/27/2026 01:38 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	VALLEY ROYALE HOME CARE		FACILITY NUMBER:	502701379
ADMINISTRATOR/ DIRECTOR:	GENARO R BAISAC JR.		FACILITY TYPE:	740
ADDRESS:	2628 COLLEGE AVE		TELEPHONE:	(209) 345-4351
CITY:	MODESTO	STATE: CA	ZIP CODE:	95350
CAPACITY: 6		CENSUS: 3	DATE:	03/27/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	07:15 AM
MET WITH:	Genaro R Baisac Jr.		TIME VISIT/ INSPECTION COMPLETED:	01:30 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 Noel Wolf Petersen, arrived unannounced to the facility to conduct an annual inspection 7:15am on 3/27/26, LPA met with administrator Genaro Baisac Jr by phone to explain the purpuse of the visit. Valley Royale Home Care is a RCFE with a current census of 3, and a total capacity of 6. 2 nonambulatory (residents makes use of a wheelchair), 1 ambulatory (makes use of a walker) . 1 resident is on hospice, there is no home health contract but hospice plan outlines nursing visits twice a week. Physical inspection included but was not limited to the kitchen, bathrooms, bedrooms, common areas, storage areas, exteriors and evacuation route gate. there is some construction going on related to replacing a vynl laminate floor in a front common area and it is in a state of disrepair. The exterior has some trash related to the construction, its traffic areas leading to the emergency exit gate unramped, a tripping hazard in the form of a unwound hose, and laundry detergent stored unlocked. LPA gave guidance to clean up the trash, move the temporary ramp to be useable, and move the hazards. The construction was described to the LPA as not modifying the subfloor, and being completed in a short order(sunday). Kitchen has adequate storage for food for 2 days perishable and 7 days nonperishable, the kitchen has lockable storage for the medication, and sharps. Toxics(except laundry detergent) are locked outside. Resident Bedrooms are furnished and have adequate space for the resident belongings and required furniture. Bathrooms have functional hardware, water temperature is measured at 105-120*F. Exterior has a pool, which is locked while not in use. Evacuation route gate swings freely and latches closed. Continued on C page.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VALLEY ROYALE HOME CARE	FACILITY NUMBER: 502701379
	VISIT DATE: 03/27/2026

NARRATIVE

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3 client files were reviewed, one has no needs and services plan, client prn documentation is an indication of yes/no dispersal, there are is 15+ day gap in the MAR administration record for Jan-Feb 2026(a mediction)) for a resident, Missing exceptions for 4 restricted conditions (oxygen administration, incontinence care, catheter, support with all ADL's). LPA gave guidance to make new 602 appointments for any clients who have changed in some aspect of thier health, then make updated needs and services plans based on those updated 602's. LPA gave guidance for the Licensee to either send granted exception letters from the department for the 4 restricted conditions, or send a Email to the LPA formally requesting exception review for those four restricted conditions.

2 clients interviewed, last client was not responsive with the interview.

5 staff Files were reviewed, two staff have expired first aid back taken back in 2019, remaining 3 do not have first aid training. Last dementia training in the staff binder is documented in 2019. Staff interviewed do not remember taking required continuing training for many years, for regular topics, dementia topics, or the restricted condition topics. Medication is being prepoured and prepared outside the presence of the resident. LPA gave guidance to not store medication outside its orginal container, and to make a plan to get the staff trained in the yearly required topics.

3 staff interviewed.

Administrator files were not reviewed, Missing the facility sketch with evacuation route, personal rights poster, and employee rights poster. LPA is asking for a copy of the workers comp and liability insurance, the LIC 610e, to be sent by email to(noel.wolfpetersen@dss.ca.gov).

Fire extinguishers are dated 13 March 2026, first aid kit has all the required items. Smoke/co alarm is functional.

Citations, technical violations, and technical assistances were issued as part of this visit, LPA recommended to elect for participation of the licensee in the Technical Support Program with regard to required documentation, staff training, and administrator responsibilities. Appeal rights were provided. A copy of the report was read over the phone to the administrator and given to the staff physically. exit interview conducted.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/27/2026 01:38 PM - It Cannot Be Edited

Created By: Noel Wolf Petersen On 03/27/2026 at 12:04 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VALLEY ROYALE HOME CARE	FACILITY NUMBER: 502701379
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation of containers of detergent stored openly outside which is accessible by 2 doors residents might use, the licensee did not comply with the section cited above in 2 out of 2 containers which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/28/2026
	Plan of Correction
1 2 3 4	LPA Proposes Putting the containers of detergent in existing lockable storage or aquiring more lockable storage, Licensee agrees. Licensee should send photos of the stored detergents by the POC date, to the LPA(619-323-4509)

Type A

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)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 record review, the licensee did not comply with the section cited above in 5 out of 5 staff records which nobody possesses an active cpr/first aid training certification from the last 2 years, presenting an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/28/2026
	Plan of Correction
1 2 3 4	LPA proposes get the staff immediately signed up for first aid training, licensee agrees. Licensee should send certificates of completion to the LPA(noel.wolfpetersen@dss.ca.gov) for the staff by the poc 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.

	Liza King
NAME OF LICENSING PROGRAM MANAGER:

	Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 03/27/2026 01:38 PM - It Cannot Be Edited

Created By: Noel Wolf Petersen On 03/27/2026 at 12:04 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VALLEY ROYALE HOME CARE	FACILITY NUMBER: 502701379
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468(c)

Personal Rights of Residents

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on Observation by the LPA, the licensee did not comply with the section cited above in not having the personal rights posted, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2026
	Plan of Correction
1 2 3 4	LPA proposes Print out the personal rights or make a copy from the client binders, and tape it to the wall. Licensee agrees, and adds to get the additional postings of the facility sketch with evacuation route and federal workers rights posters up as well. Licensee should send a photo of the required posters by the poc date to the LPA(619-323-4509)

Type B

Section Cited

CCR

87412(c)

Personnel Records

(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 record review, the licensee did not comply with the section cited above in 5 out of 5 personel records that did not have a record of yearly training for the last year, in the topics of dementia or specific restricted health conditions present in the facility or the emergency preparedness/disaster response which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2026
	Plan of Correction
1 2 3 4	LPA proposes getting a schedule to the LPA of the training by the poc date, the Administrator agrees and expresses concern about the cost of the training, LPA points to the hospice care nurse to provide free training in the hospice specific and getting signed up to the Technical Support Program offered by CCLD to get more resources in training for the basic topics to reduce cost. Licensee should send the schedule to the the LPA by the POC date(noel.wolfpetersen@dss.ca.gov)

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Liza King
NAME OF LICENSING PROGRAM MANAGER:

	Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2026

LIC809 (FAS) - (06/04)

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