<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601039
Report Date: 05/13/2022
Date Signed: 05/13/2022 01:34:58 PM

Document Has Been Signed on 05/13/2022 01:34 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:VALLE VERDE CARE HOME IIFACILITY NUMBER:
015601039
ADMINISTRATOR:GISELLE V. ADAMSFACILITY TYPE:
740
ADDRESS:7851 DIANA LANETELEPHONE:
(925) 785-8748
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY: 6CENSUS: 6DATE:
05/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Leah Dunlao, Care StaffTIME COMPLETED:
01:45 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 5/13/2022 starting at 12:35 PM, Licensing Program Analysts (LPAs) K. Nguyen and L. Francisco arrived unannounced to conduct a Case Management to follow-up on plan of correction from inspection visit conducted on 3/16/2022. Upon arrival, LPAs were greeted by Care Staff, Leah Dunlao. Administrator was not available during the visit.

LPAs inspected food supply and observed jars and cans food were discarded.

THE FOLLOWING DEFICIENCY WAS OBSERVED DURING VISIT
  • At 1:00 PM, LPAs observed fresh eggs being stored in the pantry. S1 said eggs were stored in the pantry overnight. Deficiency cleared during visit. LPAs observed staff removed eggs from pantry and discarded eggs into trash bin.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2022
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
Document Has Been Signed on 05/13/2022 01:34 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 05/13/2022 at 01:14 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: VALLE VERDE CARE HOME II
FACILITY NUMBER: 015601039

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/14/2022
Section Cited
CCR
87555(b)(23)

1
2
3
4
5
6
7
GENERAL FOOD SERVICE REQUIREMENTS
(b) The following food service requirements shall apply:(23) All readily perishable foods ..capable of supporting rapid and progressive growth of micro-organisms which can cause food infections...shall be stored in covered containers at appropriate temperatures.
1
2
3
4
5
6
7
Definciency cleared during visit. LPAs observed staff discarded eggs inside trash bin.

In addition, Administrator will review regulation and conduct in-service training with staff and submit a copy of training agenda with staff signatures to CCL by 5/20/22.
8
9
10
11
12
13
14
This requirements is not met as evidenced by: based on LPAs observation, Licensee did not comply with the regulation cited above. LPAs observed fresh eggs were being stored inside the food pantry which poses an immediate health and safety risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Bennett Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022


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