075600915-8-7-2023-15-AS-LHOS-CUGQGZ-20230807121021

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075600915
Report Date: 08/07/2023
Date Signed: 08/07/2023 12:11:31 PM

Document Has Been Signed on 08/07/2023 12:11 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 III		FACILITY NUMBER:	075600915
ADMINISTRATOR:	ALIPING, JOEL & EMILY		FACILITY TYPE:	740
ADDRESS:	5117 RAINCLOUD DR.		TELEPHONE:	(510) 222-5631
CITY:	RICHMOND	STATE: CA	ZIP CODE:	94803
CAPACITY:	6	CENSUS: 3	DATE:	08/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Joel Aliping, Administrator		TIME COMPLETED:	12:30 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	On 08/07/23 around 09:15 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a required annual inspection. LPA was greeted by one care staff upon entry and explained the purpose of the visit. Joel Aliping, Administrator (ADM) currently holds a standard certificate #(6016976740) exp. 05/24/2024. The facility’s fire clearance was approved for six (6), three (3) may be non-ambulatory residents. Upon entry, LPA observed one (1) resident watching television and the other lounging in his/her recliner chair. LPA and ADM toured the facility including, but not limited to common areas, bathrooms, bedrooms, kitchen, garage, and backyard. LPA observed mask, cough etiquette, social distancing and hand washing signs posted throughout. Routine safety drills are rotational between AM and PM schedules monthly, and was last completed 07/2023. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All hand washing stations were equipped with soap, paper towels and garbage cans. There is a surplus of PPE centrally stored in the garage that is accessible to all care staff. Hot water temperature in the shared residents' bathroom was measured at 106.4 degrees Fahrenheit (F) and the facility's temperature was 78 degrees (F). Fire extinguisher was observed full and purchased 08/06/23. Smoke/Carbon Monoxide detectors were observed operational and two (2) first aid kits are complete. continued on LIC809C...

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

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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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 III	FACILITY NUMBER: 075600915
	VISIT DATE: 08/07/2023

NARRATIVE

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...continued from LIC809.

LPA reviewed three (3) staff files; they were complete with criminal background clearances, and three (3) completed resident files.

The following forms are to be updated and submitted to CCLD:
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610 Emergency Disaster Plan
-An updated copy of Administrator Certificate(s) (Reviewed)
-Liability Insurance

Exit interview conducted and a copy of this report provided to ADM.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

LIC809 (FAS) - (06/04)

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