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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601251
Report Date: 06/20/2024
Date Signed: 06/20/2024 03:27:10 PM

Document Has Been Signed on 06/20/2024 03:27 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:VALLE VERDE CARE HOME IVFACILITY NUMBER:
015601251
ADMINISTRATOR/
DIRECTOR:
ADAMS, GISELLE V.FACILITY TYPE:
740
ADDRESS:7638 APPLEWOOD WAYTELEPHONE:
(925) 785-8748
CITY:PLEASANTONSTATE: CAZIP CODE:
94588
CAPACITY: 6CENSUS: 5DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Giselle V AdamsTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 6/20/2024 at 12:50 PM, Licensing program analyst Ardalan Gharachorloo and Licensing program manager Yvonne Flores Larios arrived unannounced to conduct a 1 year annual inspection. LPA and LPM met with administrator Giselle V Adams and explained the purpose of the visit.

LPA and LPM toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All indoor and outdoor passageways are kept free of obstruction. There are . A comfortable temperature is maintained at 72 degree F. LPA AND LPM observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents shared bathroom was measured at 106 degree F. Residents bathrooms are equipped with Grab bar and Non-skid mats. There is a minimum one week supply of Non-perishable and two day of perishable foods. Centrally stored medications and sharps were locked and inaccessible to residents. There is a pool and an iron fence surrounding it with a lock.

Smoke detectors and carbon monoxide detectors were in operating condition during the visit. Fire extinguisher was last serviced on July 14th 2023. Emergency disaster plan was last posted 06/01/2023. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 04/02/2024.

LPA and LPM reviewed 5 residents records and 5 staff records. LPA and LPM also reviewed residents medication records.

No deficiencies cited during the visit. Exit interview conducted and a copy of the report was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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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