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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601199
Report Date: 11/18/2022
Date Signed: 11/18/2022 05:03:07 PM

Document Has Been Signed on 11/18/2022 05:03 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 IIIFACILITY NUMBER:
015601199
ADMINISTRATOR:ADAMS, GISELLE V.FACILITY TYPE:
740
ADDRESS:6502 VIA SAN BLASTELEPHONE:
(925) 484-8468
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY: 6CENSUS: 6DATE:
11/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Marjorie Osia, Assistant AdministratorTIME COMPLETED:
05:15 PM
NARRATIVE
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On 11/18/2022 at 3:20PM, Licensing Program Analysts (LPAs) G. Luk and K. Nguyen arrived unannounced to conduct an Infection Control Inspection. LPAs met with Assistant Administrator, Marjorie Osia.

Upon entry, LPA's temperatures was checked and asked to filled out visitor log. LPAs observed hand sanitizer at screening station. LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, garage, and outdoor areas. LPAs observed cough etiquette, physical distancing, and signs & symptoms posted in the common areas. All sinks and bathrooms were equipped with soap and paper towel. Hand washing posters were posted at sinks and bathrooms. Fire extinguisher was last serviced on 6/29/2022.

During record review, LPAs observed visitors log and temperature log for both residents and staff. LPAs observed facility has a copy of Mitigation Plan on file. LPAs observed PPEs, food supplies, and paper supplies are sufficient.

At 3:41PM, LPAs observed the garage door was unlocked with unlocked cleaning supplies and laundry detergents accessible. Staff locked up the cleaning supplies cabinet during inspection.

At 3:43PM, LPAs observed facility was storing food items with hygiene & cleaning supplies. Staff removed the hygiene and cleaning supplies during inspection.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
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 4
Document Has Been Signed on 11/18/2022 05:03 PM - It Cannot Be Edited


Created By: Grace Luk On 11/18/2022 at 04:42 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 III
FACILITY NUMBER: 015601199

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having unlocked cleaning supplies which poses an immediate health and safety risk to persons in care.
POC Due Date: 11/19/2022
Plan of Correction
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Staff locked up the cleaning supplies in the garage during inspection.

Deficiecy cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/18/2022 05:03 PM - It Cannot Be Edited


Created By: Grace Luk On 11/18/2022 at 04:42 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 III
FACILITY NUMBER: 015601199

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(25)
General Food Service Requirements
(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above by having food items stored with hygiene & cleaning supplies which poses a potential health and safety risk to persons in care.
POC Due Date: 11/19/2022
Plan of Correction
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2
3
4
Staff removed the cleaning and hygiene supplies during inspection.

Deficiency cleared.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4