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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075600915
Report Date: 04/12/2023
Date Signed: 04/24/2023 10:35:52 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
10/28/2021 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20211028125726
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:
04/12/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Emily Aliping, Co-AdministratorTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Facility failed to meet reporting requirements:
INVESTIGATION FINDINGS:
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Amended report to update findings on 04/24/23 at 10:00 AM from 04/12/23 at 09:00 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the complaint findings for the above allegation. LPA met with Emily Aliping, Co-Administrator (Co-ADM) and explained the purpose for the visit.
Facility failed to meet reporting requirements:
SUBSTANTIATED

During the course of the investigation LPAs L. Holmes and L. Francisco conducted interviews, reviewed emails, after visit summaries, weight records, medical records, incident reports and files for Residents’ (R1, R2 and R3). LPA L. Holmes reviewed seven (7) Incident Reports on file with CCL dated from 05/14/18 to 10/21/21 for R1, R2, R3 and R4. Three (3) of the seven (7) reports did not reference notification to the Responsible Party(s) RP), or to the Regional Center of the East Bay (RCEB).
...continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
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 5
Control Number 15-AS-20211028125726
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: 04/12/2023
NARRATIVE
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...amendment continued from LIC9099

Interviews with W1 revealed that the incident involving R1 diagnosed with pneumonia on 03/01/2020 was not reported to RCEB until 03/13/20, twelve (12) days later. On 04/12/23, S1 did not provide any additional documentation, UIR’s, faxes or emails as proof notification within twenty-four (24) hours or seven (7) days for R1.

Type B Deficiency is cited per California Code of Regulations, Title 22, and listed on LIC 809D. Failure to submit Proof of Corrections (POC's) by Plan of Correction date and/or repeat deficiencies within 12-month period may result in civil penalties.

Exit interview conducted, Appeal Rights and a copy of this report provided to Co-ADM.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
10/28/2021 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20211028125726

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:
04/12/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Emily Aliping, Co-AdministratorTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Licensee does not assist resident with obtaining medical care
Facility does not meet resident's nutritional needs
INVESTIGATION FINDINGS:
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This is an amended report from 4/12/23. On 04/24/12/23 at 10:00 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the complaint findings for the above allegation. LPA met with Emily Aliping, Co-Administrator (Co-ADM) and explained the purpose for the visit.

During course of the investigation LPA Francisco and LPA Holmes collected and reviewed records that included facility menu, needs and service plans, physicians reports, after visit summary for medical appointments attended, and weight records for 2020 and 2021. Interviews were conducted with witnesses and staff from 02/16/23 to 04/12/23. Interviews were not able to be obtained for residents as they are non-verbal.

Allegation: Facility does not meet resident's nutritional needs
During the facility’s Health and Safety check conducted 02/04/22, annual Infection Control Inspection 03/09/22, and unannounced complaint visit on 02/16/23, the food supply was checked and there was an adequate supply of 2-day perishables and 7-day supply of non-perishables...continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20211028125726
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: 04/12/2023
NARRATIVE
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...amendment continued from 9099A
The menu consisted of a variety of foods and beverages including, but not limited to, coffee, juice, milk, oranges, pineapples, carrots, salmon, spaghetti, and chicken.

On 02/16/23 LPA observed C2 preparing a hot meal on the stove top and preparing place settings to serve lunch for the residents in care. On 11/2/2021 LPA Francisco requested for records for R3 and on subsequent visit 2/16/2023 LPA Holmes requested additional records for R1 and R2 that included physicians reports, after visit summary for medical appointments attended, and weight records for 2020 and 2021. Medical records revealed R3 had a history of being underweight since 06/29/2013. Documentation showed R2 and R3 had slight weight gain during 2021. Interview with W2 in November 2021 stated R3 was improving and eating.

Allegation: Licensee does not assist resident with obtaining medical care

R1's attending hospital was Kaiser Permanente, Richmond, CA. W1 and S1 did not provide documentation for time period surrounding the allegations for the year 2021.

Documentation was received for R2 from appointments attended at Contra Costa Health Services (CCHS) in Martinez, CA and San Pablo, CA for various appointments in February 2021. Each month from May to July 2021 R2 returned for patient recheck visits in ophthalmology without any noted concerns. Documentation was also received for R3’s medical appointments attended at Sutter Health in Berkeley, CA for various appointments in January, February, and May 2021, additionally R3 had monthly visits with podiatrist from January to June in 2021. Documentation did show there were overdue vaccines and rescheduled appointments. S1 stated that overdue or rescheduled appointments may have been related to COVID-19 procedures or residents' behavior. S1 and S3 was able to secure a physician for facility visits.

Based on interviews and record review the allegations above may have happened or is valid, however there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED.

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: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20211028125726
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: 04/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/19/2023
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements (a) Each licensee shall furnish...such reports...including, but not limited to, the following: (1) A written report shall be submitted...to person responsible for the resident within seven days…-This requirement has not been met as evidenced by:
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Licensee/Administrator agreed to review regulation 87211 with staff, report incidents to RP’s and CCLD, self-certify completion, and submit written proof to CCL by POC date.
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Based on LPAs records review and interviews, Licensee/Administrator failed to ensure that a written report of the residents’ occurrences were submitted to the responsible party and CCL.
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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: 04/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5