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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601251
Report Date: 06/09/2021
Date Signed: 06/09/2021 12:24:12 PM

Document Has Been Signed on 06/09/2021 12:24 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 IVFACILITY NUMBER:
015601251
ADMINISTRATOR:ADAMS, GISELLE V.FACILITY TYPE:
740
ADDRESS:7638 APPLEWOOD WAYTELEPHONE:
(925) 785-8748
CITY:PLEASANTONSTATE: CAZIP CODE:
94588
CAPACITY: 6CENSUS: 6DATE:
06/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Majorie OsiaTIME COMPLETED:
12:30 PM
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On 6/09/2021 at 10:30am, Licensing Program Analyst (LPA) A. O'Hollaren arrived unannounced to conduct Infection Control Inspection. LPA met with Staff, S1 and explained the purpose of the visit. LPA called Administrator, Giselle Adams. Assistant Administrator Marjorie Osia arrived at approximately 10:40am.

During the inspection, LPAs toured facility including but not limited to common areas, hand washing stations, bedrooms, kitchen and backyard. LPA observed COVID-19 signage including physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towels and garbage. Hand washing posters were posted at hand washing stations.

During record review, LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE, food and paper supplies are sufficient. Screening questions, visitor's sign in and temperature log were maintained at the facility for all visitors, residents and staff. Residents and staff are checked for COVID-19 symptoms twice daily. Common areas are disinfected twice every day.

LPA observed laundry detergent, gardening solutions and cleaning supplies accessible to residents in unlocked garage.

The following deficiency was observed (See LIC 809D) and cited from the California Code of Regulations, Title 22 and California health and safety code. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted and a copy of this report and appeal rights provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2021
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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Document Has Been Signed on 06/09/2021 12:24 PM - It Cannot Be Edited


Created By: Allison O'Hollaren On 06/09/2021 at 11:55 AM
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 IV
FACILITY NUMBER: 015601251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of Person with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. LPA observed laundry detergent, gardening solutions, and cleaning supplies in unlocked garage accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2021
Plan of Correction
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Assistant Administrator agrees to lock all laundry detergent, gardening supplies, and cleaning supplies in cabinet.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2021


LIC809 (FAS) - (06/04)
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