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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600702
Report Date: 10/21/2021
Date Signed: 10/21/2021 12:30:53 PM

Document Has Been Signed on 10/21/2021 12:30 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:VALLEY VIEW CARE HOME IIFACILITY NUMBER:
075600702
ADMINISTRATOR:ALIPING, JOEL & EMILYFACILITY TYPE:
740
ADDRESS:4928 SWEETWOOD DRIVETELEPHONE:
(510) 222-5643
CITY:RICHMONDSTATE: CAZIP CODE:
94803
CAPACITY: 5CENSUS: 5DATE:
10/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Emily Aliping, AdministratorTIME COMPLETED:
12:50 PM
NARRATIVE
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On 10/21/2021 at 9:50 AM, Licensing Program Analysts (LPAs) L. Francisco and L. Holmes arrived unannounced to conduct Infection Control Inspection. LPAs met with Administrator, Emily Aliping and explained the purpose of the visit.

During the Infection Control Inspection, LPAs toured facility with Administrator including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPE supply. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

-At approximately 10:20am, LPAs observed reclining chairs obstructing exit door. Deficiency cleared during visit. LPAs observed staff remove recliner from passageway.

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

Exit interview conducted with Administrator. Due to technical issue, Appeal Rights and a copy of report provided via email.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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 10/21/2021 12:30 PM - It Cannot Be Edited


Created By: Lizette Francisco On 10/21/2021 at 11:52 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: VALLEY VIEW CARE HOME II
FACILITY NUMBER: 075600702

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, the licensee did not comply with the section cited above. LPAs observed chair recliners obstructing an exit door which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2021
Plan of Correction
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DEFICIENCY CLEARED DURING VISIT. LPAs observed staff remove reclining chairs from obstructing exit door.

In addition, Administrator will review regulation and train staff and submit a copy of training with staff signature to CCL by 11/4/2021.
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:Lizette Francisco
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2021


LIC809 (FAS) - (06/04)
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