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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600915
Report Date: 02/04/2022
Date Signed: 02/04/2022 04:40:33 PM

Document Has Been Signed on 02/04/2022 04:40 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 IIIFACILITY NUMBER:
075600915
ADMINISTRATOR:ALIPING, JOEL & EMILYFACILITY TYPE:
740
ADDRESS:5117 RAINCLOUD DR.TELEPHONE:
(510) 222-5631
CITY:RICHMONDSTATE: CAZIP CODE:
94803
CAPACITY: 6CENSUS: 3DATE:
02/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Joel Aliping, AdministratorTIME COMPLETED:
03:10 PM
NARRATIVE
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On 02/04/2022 starting at 2:10 PM, Licensing Program Analysts (LPAs) L. Ibo & L. Holmes conducted a health and safety check as a result of department receiving a priority 1 complaint. LPAs met with S2, LPAs called Administrator Joel Aliping, Administrator arrived at the facility after 45mins, LPAs explained the purpose of the visit.

During the health and safety check, LPAs toured the building including but not limited to common areas, bathrooms, bedrooms and outdoor area. .

Food supply was checked and there is an adequate supply of 2 day perishables and 7 day non-perishables. LPAs observed rooms were furnished appropriately, clean and in good repair. All bathrooms and showers were equipped with grab bars and safety/nonskid floors/mats. Hot water temperature in random resident's bathroom was measured at 107.5 degrees Fahrenheit.

There is an empty swimming pool located at the backyard which was gated and locked. All indoor and outdoor passageways were kept free of obstruction and fire hazards. There is an active telephone line to use for emergency purposes.

...Continued to LIC80C...
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 III
FACILITY NUMBER: 075600915
VISIT DATE: 02/04/2022
NARRATIVE
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LPAs observed the following:

Second floor bathroom faucet was leaking.
Cleaning products was inaccessible to clients in care. – corrected during the visit.
Kitchen cabinet door and second floor patio screen door was not in good repair.

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Joel Aliping.

Exit interview conducted and a copy of this report and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/04/2022 04:40 PM - It Cannot Be Edited


Created By: Leslie Ibo On 02/04/2022 at 03:48 PM
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 III
FACILITY NUMBER: 075600915

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/04/2022
Section Cited
CCR
80087(g)

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80087(g): Buildings and Grounds: Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement was not met as evidence by:
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Staff locked chemical products and moved to locked cabinet.

Deficiency was cleared during the visit,
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Based on LPAs observation, Administrator failed to ensure cleaning products are was inaccessible to clients, which poses an immediate health and safety risk to clients in care.
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Type B
02/15/2022
Section Cited
CCR80087(a)

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80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidence by:
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Administrator agreed to repair the kitchen cabinet, faucet sink and screen door by POC date, proof of correction need to submit to CCL by POC date.
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Based on LPAs observation, Administrator failed to ensure that kitchen cabinet, faucet sink and second floor screen door by the patio is in good repaid, which poses an potentia health and safety risk to clients in care.
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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:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2022


LIC809 (FAS) - (06/04)
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