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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075600915
Report Date: 02/16/2023
Date Signed: 02/16/2023 10:57:10 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2023 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230210082022
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:
02/16/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Joel Aliping, AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Appropriate administrator is not present on the facility premises a sufficient number of hours
INVESTIGATION FINDINGS:
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On 02/16/2023 at 09:15 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an initial 10-day complaint visit. Upon arrival, LPA met with Care Staff Margarita Dulagan and explained to the reason for the visit. Joel Aliping, Administrator arrived about 10 minutes later.

During the investigation, LPA interviewed Staff #1 (S1), Staff #2 (S2), Staff #3 (S3, and Witness #1 (W1). LPA reviewed Guardian and sent an email to S1 and S3 requesting the facility’s LIC 308, LIC 500, and Resident Roster. During the visit, LPA interviewed S3, obtained a Resident Roster and Direct Care Staff Schedule.

continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20230210082022
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/16/2023
NARRATIVE
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...continued from LIC 9099

While conducting interviews on 02/13/23, S1, S2, and W1 stated that S3 was in the Philippines. S1 stated that he/she is the Administrator of Valley View Care Home II and that S2 and W1 were overseeing the residents while S3 was out of the country; S3 is the Co-Administrator at Valley View Care Home III. Although S1 and S3 are both Administrators and Licensees, S1 states that S3 oversees this facility. W1 confirmed working or volunteering 2 -3 hours a day as needed at the facility helping with groceries and prescriptions to help S3 while out of the country. Guardian records revealed that W1 is not associated with the facility. S2 stated that he/she has been providing 24 hours of care since 12/25/22 with the companionship of W1. Although S1 is also the Co-Administrator and Licensee for this facility, S1 said that she is the Administrator and only oversees Valley View Care Home II. Per RP, this facility is vendored by RCEB and sufficient staff was not on the premises since 12/25/2022. S3 did not inform CCL of his/her absence, there is not an LIC 500 or LIC 308 on file. The most current Direct Care Staff Schedule is dated 10/31/2022 to 11/06/2022 with S2 and S3 as the care staff.

Based on LPA’s interviews conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D and civil penalty assessments on LIC 421.

Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20230210082022
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/16/2023
Section Cited
CCR
87355(d)
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87355 Criminal Record Clearance (d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.
-This requirement is not met as evidenced by
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On 02/13/23 W1 agreed to not assist residents in care at the facility. Administartor to submit documentation to Guardian or CCLD for Criminal Record Clearance on 03/02/2023
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-Based on interviews and review of records, the licensee did not comply with the above Regulation by not associating and obtaining Criminal Record Clearance for the W1 which poses a potential safety risk to persons in care.
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Type B
02/23/2023
Section Cited
HSC
87411(a)
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87411 Personnel Requirements – General
(a)Facility personnel shall at all times be sufficient in numbers...Additional staff shall be employed... to perform office work, cooking, house cleaning, laundering...
-This requirement is not met as evidenced by
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Administrator to submit an updated LIC 500, read the regulation 87411 and submit self-certification to CCLD by POC date.
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Based on interviews and review of records, the Administrator/Licensee did not comply with the above Regulation by facility personnel not being sufficient in numbers.
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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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3