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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600702
Report Date: 10/11/2022
Date Signed: 10/11/2022 04:34:52 PM

Document Has Been Signed on 10/11/2022 04:34 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: 4DATE:
10/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Administrator, Emily AlipingTIME COMPLETED:
04:45 PM
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On 10/11/2022 at 03:10 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an annual Infection Control Inspection. LPA was greeted by one Care Staff upon entry and explained the purpose for the visit. The Administrator Emily Aliping was telephoned by the Care Staff and arrived at 03:20 PM.

Facility has a COVID-19 mitigation plan on file. LPA received a staff and resident roster. LPA was screened at the entry with a thermometer and hand sanitizer. Masks, face shields, gowns, gloves, additional sanitizer COVID-19 signage, and a visitor sign-in log is centrally stored inside the facility that is accessible to all care staff. LPA toured the facility including, but not limited to common areas, bedrooms, kitchen, and backyard. LPA observed mask, cough etiquette, social distancing and hand washing signs are posted throughout. All shared areas to have covered garbage cans. Staff to wear mask and encourage residents/clients that can to do so. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All hand washing stations were equipped with soap, paper towels and covered garbage cans. Hot water temperature was measured at 109.4 degree Fahrenheit (F) and the facility's temperature was 69 degree (F). Fire extinguisher was observed full and last inspected on 05/13/2022. Smoke/Carbon Monoxide detectors were observed operational and first aid kit complete.

The following forms are to be updated and submitted to CCLD by 10/25/2022:
-LIC500 Personnel Report (Staff roster reviewed)
-LIC308 Designation of Administrative Responsibility
-LIC610 Emergency Disaster Plan (Reviewed)
-An updated copy of Administrator Certificate(s)
-Infection Control Plan

Exit interview conducted and a copy of this report provided to Administrator Emily Aliping.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2022
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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