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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600915
Report Date: 04/12/2023
Date Signed: 04/12/2023 10:51:53 AM

Document Has Been Signed on 04/12/2023 10:51 AM - 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:
04/12/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Emily Aliping, Co-Administrator (Co-ADM) TIME COMPLETED:
11:00 AM
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On 04/12/23 at 10:05 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver complaint finding for #15-AS-20211028125726. A case management is being conducted and LPA met with Emily Aliping, Co-Administrator (Co-ADM) and explained the reason.


The “After visit summaries” for R2 revealed the following on the noted dates: On 07/07/21, overdue visits for COVID-19 vaccine (2-Pfizer 2 dose series); overdue since 02/21/21, postponed to 05/19/21 and 07/02/21. The Shingles vaccination sequential (2 of 2) was overdue since 03/19/21. On 08/04/21, ophthalmology visit was rescheduled for R2 by S1. Proof of R1, R2, and R3’s dental and ophthalmology exams, and/or attempts to schedule exams were not provided to CCL by 03/24/23 when requested from S1 on 02/16/23.

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 provide to Co-ADM,
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 licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2023
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 04/12/2023 10:51 AM - It Cannot Be Edited


Created By: Lisha Holmes On 04/12/2023 at 10:42 AM
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: 04/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/19/2023
Section Cited
CCR
87464(f)(6)

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87464 Basic Services (f) Basic services shall at a minimum include: (6) Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services.
-This requirement has not been met as evidenced by:
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Licensee/Administrator agreed to review regulation 87464 and resident records in order to make arrangements to meet health needs of residents in care. Submit written proof of self-certification to CCL by POC date.
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Based on LPAs records review and interviews, Licensee/Administrator failed to ensure R2’s vaccinations were current and provide proof of residents dental and ophthalmology exams.
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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: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


LIC809 (FAS) - (06/04)
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