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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600915
Report Date: 10/03/2022
Date Signed: 10/03/2022 03:29:22 PM

Document Has Been Signed on 10/03/2022 03:29 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:
10/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Joel Aliping, AdministratorTIME COMPLETED:
03:45 PM
NARRATIVE
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On 10/3/2022, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct a Case Management visit. LPA met with Administrator Joel Aliping, LPA explained the purpose of the visit.

During the facility tour, LPA observed second floor porch area was unorganized, there was overhanging tree branches by the stairs going down to the backyard which potentially obstructing anyone going down that stairs. LPA explained to Administrator the importance of maintaining the facility clean and organize and to refer to the citation cited.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
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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Document Has Been Signed on 10/03/2022 03:29 PM - It Cannot Be Edited


Created By: Leslie Ibo On 10/03/2022 at 03:20 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: 10/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2022
Section Cited
CCR
87303(a)

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Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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Administrator agrees to cut the overhanging branches at the second-floor porch and organize the porch. Administrator agreed to send a picture as proof of correction to CCL by POC date.
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Based on record review, Licensee failed to organize and clean the facility which poses potential 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: 10/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2022


LIC809 (FAS) - (06/04)
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