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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 557001183
Report Date: 12/05/2023
Date Signed: 12/05/2023 04:09:22 PM

Document Has Been Signed on 12/05/2023 04:09 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 OAKS FAMILY HOMEFACILITY NUMBER:
557001183
ADMINISTRATOR:MONA B. GASKILLFACILITY TYPE:
735
ADDRESS:16649 ANDERSON ROADTELEPHONE:
(209) 928-1196
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY: 8CENSUS: 8DATE:
12/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Andrea Hall-Administrative AssistantTIME COMPLETED:
04:00 PM
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On 12/5/23 at approximately 9:45am, Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual inspection. There was no one at the facility. LPA Jensen made various attempts to reach the Licensee. The Licensee returned LPA Jensen's call and explained that the clients were at various outing but agreed to return to the facility to meet with the LPA. LPA Jensen met with briefly with the Licensee and remained with the assistant administrator for the inspection.

LPA Jensen toured the grounds and interior of the facility. LPA Jensen observed outdoor furniture and shaded areas for the clients to engage in outdoor activities. There are various gardening projects in the yard that are maintained by the clients. The facility runs on well water and the latest bacteriological analysis is being forward to LPA Jensen electronically. LPA Jensen observed a clothes dryer and a refrigerator that was replaced being stored in the back yard as well as a headboard and broken palate. The facility maintains extra storage water on the premises for drought conditions. The facility is currently undergoing an irrigation project to divert water away from the physical plant in the event of flooding. All window screens were observed to be in good repair.

LPA Jensen toured the interior of the facility. LPA Jensen observed adequate lighting and furniture throughout the facility. All required postings were observed. The facility was decorated for upcoming holidays. LPA Jensen observed a variety of activities for client engagement and reviewed photos from group vacations that the clients have taken together. The temperature inside the facility was 72 degrees which is in compliance. The water temperature in the shared bathroom was 116 degrees which is in compliance. There are night lights available in the hallways

LPA Jensen tested the smoke detector and carbon monoxide detector and found them to be in good working order. The facility conducts fire drills and keeps a log of drills completed. The facility maintains first aid kits and a supply of emergency food and emergency lighting.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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 OAKS FAMILY HOME
FACILITY NUMBER: 557001183
VISIT DATE: 12/05/2023
NARRATIVE
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LPA Jensen reviewed the emergency disaster plan and found it to be in compliance. The facility has a COVID mitigation plan but has not yet submitted an Infection Control Plan. Technical assistance was provided.

LPA Jensen observed the facility to maintain an adequate food supply, linen supply and personal hygiene supply. LPA Jensen observed some stains on the carpeting, possible mold in the common bathroom adjacent to the kitchen, a shower door that does not seal properly due to decomposition, several missing light switch plates, and a missing kitchen light panel. LPA Jensen observed trash cans without lids in resident rooms. and bathroom.

LPA Jensen reviewed 7 of 8 resident files. LPA Jensen observed medical documentation for x-rays performed as a result of a fall for Resident 1 (R1) An incident report was not received for this fall. LPA Jensen did not observe any incident reports in 7 of 7 resident files made to the Department. It should be noted that reports made to the Regional Center and other agencies were present in the files. LPA Jensen reviewed 4 staff files. Interviews were conducted with 2 clients and 1 staff member.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

LPA Jensen requested a current LIC 500, liability insurance and LIC 308.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
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Document Has Been Signed on 12/05/2023 04:09 PM - It Cannot Be Edited


Created By: Maja Jensen On 12/05/2023 at 03:55 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 OAKS FAMILY HOME
FACILITY NUMBER: 557001183

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's observation of various items that should be stored or discarded in the backyard and based on multiple items inside the physical plant that need attention such as, light switch plates, shower door, mold, broken shower head and stained carpets, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2023
Plan of Correction
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The Licensee agrees to submit a written plan to LPA Jensen by email that includes a timeline for compliance.
Type B
Section Cited
CCR
80061(b)
Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's observation of resident medical records showing R1 had x-rays in relation to fall that was not reported and based on the lack of incident reports sent to Department in 7 of 7 files the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2023
Plan of Correction
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The Licensee and/or Administrator agree to conduct in-service training with staff and will email LPA Jensen proof of training by the POC 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:Lisa Rios
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023


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