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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 557001183
Report Date: 04/15/2024
Date Signed: 04/15/2024 05:12:56 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/11/2024 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20240411154031
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: 7DATE:
04/15/2024
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Doug CasmerTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff does not provide residents with food of good quality.
Facility bathroom has mold.
INVESTIGATION FINDINGS:
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On 4/15/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to open a complaint investigation in to the above listed allegations.PA Jensen met care provider Doug Casmer and explained the purpose of today's visit.

LPA Jensen inspected the contents of the refrigerator and pantry. LPA Jensen observed 4 packages of lunch meat, cheese slices that were expired and a bag of jalapenos that had mold in the refrigerator. LPA Jensen observed items in the freezer with no dates to indicate when they were frozen and were past the listed expiry dates.

LPA Jensen inspected the bathroom next to the kitchen and observed what appeared to be mold on the ceiling and around the shower door. LPA Jensen interviewed a resident who explained that the shower leaks and water goes onto the linoleum floor. LPA Jensen observed that there is a gap between the linoleum and sub floor next to the door where water intrusion can take place.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 27-AS-20240411154031
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/15/2024
NARRATIVE
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LPA Jensen also observed that the shower was installed with a gap at the upper left corner. LPA Jensen ran the shower for approximately 4 minutes and observed the floor to be slightly wet. A significant amount of water leaked from the shower door on to the floor when LPA Jensen opened the shower door to turn off the water.

Based on LPA Jensen's observation of expired food and undated food the allegation of "Staff does not provide residents with food of good quality" is SUBSTANTIATED. an allegation of substantiated means that the preponderance of evidence of standard has been met.

Based on LPA Jensen's observation of mold in the shower downstairs next to the kitchen and areas on floor and wall for potential water intrusion, the allegation of "facility bathroom has mold" is substantiated.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. A civil penalty is also being assessed for a repeat violation.

LPA Jensen conducted an exit interview with Mona Gaskill by telephone. A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20240411154031
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/14/2024
Section Cited
CCR
80087(a)
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Buildings and Grounds
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 was not met as evidenced by:
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The Licensee agrees to contact a builder to assess the extent of the bathroom mold and develop a remediation to be submitted to the Department for approval by 5/15/24. The residents will primarily use the other bathrooms in the facility effective immediately.
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This requirement was not met as evidenced by LPA Jensen's observation of mold in the bathroom and observation of gaps on the wall and floor where water intrusion is likely. This poses a potential risk for the health, safety and personal rights of residents in care.
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Type B
05/15/2024
Section Cited
CCR
80076(a)
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Food Service
All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. ... All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidenced by:
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The Licensee agrees to conduct an in-service training regarding proper food storage and will send proof of plan of correction completion to the Department.
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Based on LPA Jensen's observation of expired food product in the refrigerator and pantry. This poses a potential risk to the health, safety and personal rights of residents 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.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4