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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600915
Report Date: 07/23/2024
Date Signed: 07/23/2024 12:20:40 PM


Document Has Been Signed on 07/23/2024 12:20 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 IIIFACILITY NUMBER:
075600915
ADMINISTRATOR:ALIPING, JOEL & EMILYFACILITY TYPE:
740
ADDRESS:5117 RAINCLOUD DR.TELEPHONE:
(510) 222-5631
CITY:RICHMONDSTATE: CAZIP CODE:
94803
CAPACITY:6CENSUS: 3DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Margarita Dulagan, Care StaffTIME COMPLETED:
12:40 PM
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On 07/23/24 around 09:10 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) arrived shortly after and currently holds a standard certificate #(6016976740) exp. 05/24/2024; awaiting new certificate. The facility’s fire clearance was approved for six (6), three (3) may be non-ambulatory residents. Margarita Dulagan, approved to sign report.

Upon entry, One (1) resident was in their room and the other at the Day Program. LPA and ADM toured the facility including, but not limited to common areas, bathrooms, bedrooms, kitchen, storage, front yard 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, and was last completed 03/2024.

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 107.8 degrees Fahrenheit (F) and the facility's temperature was 71 degrees (F). Fire extinguisher was observed full and inspected 07/12/24. Smoke/Carbon Monoxide detectors were observed operational and two (2) first aid kits were complete. Licensee to tighten the door knob, and lower cabinet hinges in bathroom #2 upstairs (add locks if necessary), hire a landscaper for the yard to cutback the vines and weeds, haul away debris, iron gate, window screen, bikes and solar panels and other miscellaneous items from the storage, garage, and inside the facility.

Continued on LIC809C...
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
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 3


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: 07/23/2024
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...continued from LIC809.

LPA reviewed two (2) staff files; they were complete with criminal background clearances, and two (2) completed resident files.

The following forms are to be updated and submitted to CCLD 08/13/24:
-LIC500 Personnel Report - Update
-LIC308 Designation of Administrative Responsibility - Update
-LIC610 Emergency Disaster Plan - Update
-Resident Roster - Update
-An updated copy of Administrator Certificate(s) (Reviewed)
-Liability Insurance
-Updated Facility Sketch to include storage.

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

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3