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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601251
Report Date: 01/20/2023
Date Signed: 01/20/2023 12:10:35 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/12/2023 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20230112155837
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: 5DATE:
01/20/2023
UNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Giselee Adam, AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not refund fees paid in advance after death of resident to the resident’s estate.
INVESTIGATION FINDINGS:
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On 1/20/23 at 10:00AM, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced complaint visit, met with caregiver Hannah Bognot. Administrator (ADM) Giselle Adam was not available at the time. Hannah caregiver gave Giselle a called for LPA to explained the purposed of the visit. Administrator later arrived at 11:00AM.

Based on record reviews and interviews, resident (R1) was admitted at the facility on 08/24/22 under hospice care. ADM confirmed R1's authorized representative (POA) made an advance payment for the Month of October 2022 for R1's care. On 10/10/22, R1 passed away at the facility and her personal belongings were removed the next day 10/11/22.

Continued on next page, LIC 9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20230112155837
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 IV
FACILITY NUMBER: 015601251
VISIT DATE: 01/20/2023
NARRATIVE
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LPA discussed refund check for the reminder total of $4580.65 based on the remaining 20 days total refund due to POA for the month of October 2022.

Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be SUBSTANTIATED.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in 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: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20230112155837
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 IV
FACILITY NUMBER: 015601251
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/26/2023
Section Cited
HSC
1569.652(c)
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1569.652

Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds
(c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed.

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LPA discussed with Administrator upon the refunding of the remainder 20days by the POC dates.
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This requirements was not met as evidenced by not refunding of R1's remaining 20days in the month of October 2022. R1 pass away 10/10/22 and R1 belonging was removed on 10/11/22 which was in violation of health and safety code.
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Administrator agree to refund the amount of 4580.65 to R1 POA and send a confirmation to LPA by POC date.
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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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3