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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600702
Report Date: 08/26/2024
Date Signed: 08/26/2024 01:26:40 PM


Document Has Been Signed on 08/26/2024 01:26 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:VALLEY VIEW CARE HOME IIFACILITY NUMBER:
075600702
ADMINISTRATOR:ALIPING, JOEL & EMILYFACILITY TYPE:
740
ADDRESS:4928 SWEETWOOD DRIVETELEPHONE:
(510) 222-5643
CITY:RICHMONDSTATE: CAZIP CODE:
94803
CAPACITY:5CENSUS: 3DATE:
08/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Emily Aliping, AdministratorTIME COMPLETED:
01:40 PM
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On 08/26/2024 around 09:30 AM, LPA L Holmes arrived at the facility. LPA Telephone and left a message for Emily Aliping, Administrator (ADM) and explained the purpose of the visit. ADM arrived about 15 minutes later after returning from physician with R1.

LPA and ADM toured the facilely including but not limited to the common areas, dining room, bathroom, kitchen, bedrooms. The facility consists 3 residents but two were at the day program. All outdoor and indoor passageways were free of obstruction. There were no bodies of water present. A comfortable temperature was maintained at 73 degrees Fahrenheit (F). LPA observed lighting in all areas to be adequate for the comfort and safety of the residents. The hot water temperature in the shared restrooms were measured at 105.2 and 106.5 degrees (F). The shared restroom had paper towels, soap and garbage cans; all areas were safe and sanitary. PPE, sanitizer, and paper goods remain sufficient. There is a 2-day supply of perishable foods and a 7-day supply of non-perishable foods.

...continued on LIC9099C.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: VALLEY VIEW CARE HOME II
FACILITY NUMBER: 075600702
VISIT DATE: 08/26/2024
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...continued from LIC9099.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was observed full and serviced 03/08/24. Emergency Disaster Plan is updated. Safety drills are rotational between monthly, last on 08/10/24. LPA reviewed three (3) staff files, and three (3) resident files.

The following forms are to be updated and submitted to CCLD 09/02/24:
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610E Emergency Disaster Plan (Reviewed)
-An updated copy of Administrator Certificate
-Resident Roster
-CNA Surety Bond

Exit interview conducted and a copy of this report provided to ADM.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024
LIC809 (FAS) - (06/04)
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