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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600883
Report Date: 10/09/2026
Date Signed: 10/09/2026 04:37:28 PM

Document Has Been Signed on 10/09/2026 04:37 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SUNVALLEY RESIDENTIAL CARE HOMEFACILITY NUMBER:
075600883
ADMINISTRATOR/
DIRECTOR:		MAUER, KEITH MFACILITY TYPE:
740
ADDRESS:67 COLLEGE WAYTELEPHONE:
(925) 323-6428
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 6CENSUS: 5DATE:
10/09/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Adelina Pilarski, LicenseeTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 10/09/2026 at 1:15 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a case management visit regarding incident report received by the Community Care Licensing Division (CCLD) on 10/06/2026. LPA met with caregiver, Marjoy Bacuyag, and explained the purpose of the visit. Marjoy contacted Licensee, Adelina Pilarski, by phone to inform her of the visit. Ms. Pilarski arrived shortly after. Administrator, Keith Mauer, wasn't available.

On 10/06/2026, CCLD received an Unusual Incident Report (UIR) regarding an incident that occurred on 10/05/2026. The report indicated that Resident (R1) exited the facility through a door without staff awareness. The report further indicated that staff contacted R1’s responsible party, initiated a search for R1, and notified law enforcement. Law enforcement subsequently located R1 and transported R1 to the emergency room (ER) for evaluation.

LPA interviewed Staff (S1 and S2). S1 and S2 both stated that visitors were visiting another resident and that R1 was mingling with the visitors. S1 and S2 stated that Pleasant Hill Police Department located R1. S2 further stated that R1 was located at a Chevron gas station in Concord sometime after 11:00 PM. S1 and S2 stated that R1 sustained a cut on R1's head. S1 stated that R1 received stitches. R1's After Visit Summary (ER) wasn't available to review.



LIC809-C Continued...
Bennett Fong
Lori Alexander-Washington
DATE: 10/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SUNVALLEY RESIDENTIAL CARE HOME
FACILITY NUMBER: 075600883
VISIT DATE: 10/09/2026
NARRATIVE
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LIC809-C (Page 2)

LPA requested to review R1’s facility file, including the Physician’s Report, Identification and Emergency Information form, Appraisal/Needs and Services Plan, and incident reports. However, S1 stated that they did not have access to the requested documents.

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING THE VISIT:

  • At 1:57 PM, LPA observed a padlock on the side gate.
  • At 1:59 PM, LPA observed a padlock on the opposite side gate.
  • At 2:30 PM, LPA was informed by S1 that R2 passed away approximately 5 months ago. LPA did a review and did not observe that an incident report and death report was submitted to CCLD.


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Lori Alexander-Washington
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 10/09/2026 04:37 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 10/09/2026 at 02:57 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: SUNVALLEY RESIDENTIAL CARE HOME
FACILITY NUMBER: 075600883

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/10/2026
Section Cited
CCR
87202(a)

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87202 Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal....

This requirement is not met as evidenced by:
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Administrator agreed to remove the locks from gates and smed a photo to CCLD by POC date.

Locks were removed during visit.
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Based on observation, the licensee did not comply with the section cited above in by not having pad locks attached to two side gates which poses an immediate health and safety risk to persons in care.
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Immediate Civil Penalty Assesed $500.00
Type A
10/16/2026
Section Cited
CCR87468.2(a)(4)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, :(4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers...

This requirement is not met as evidenced by:
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Administrator agreed to read the regulation and self certify understanding going forward and send to CCLD by POC due date.
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Based on interview, and record review, the licensee did not comply with the section cited above in by providing care and supervision when R1 eloped on 10/05/26 which posed an immediate health and safety risk to persons 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 10/09/2026 04:37 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 10/09/2026 at 03:21 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: SUNVALLEY RESIDENTIAL CARE HOME
FACILITY NUMBER: 075600883

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/16/2026
Section Cited
CCR
87506(d)

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87506 Resident Records
(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
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Administrator agreed to send records to CCLD by POC due date.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in by not having residents', R1's, records available, including but not limited to physician's report, Appraisal Needs and Services, After Visit Summary Report from ER visit on 10/5/26, ID/Emergency Info., which poses a potential health, safety or personal rights risk to persons in care.
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Type B
10/16/2026
Section Cited
CCR87211(a)(1)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

This requirement is not met as evidenced by:
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Administrator agreed to read the regulation and self certify reading and understaning the regulation and will send a incident report and death report for R2 to CCLD by POC due date.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in by not reporting R2's hospitalization and death to licensing which poses a potential health, safety or personal rights risk to persons 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 10/09/2026 04:37 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 10/09/2026 at 03:40 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: SUNVALLEY RESIDENTIAL CARE HOME
FACILITY NUMBER: 075600883

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/16/2026
Section Cited
CCR
87405(a)

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87405 Administrator - Qualifications and Duties
(a) All facilities shall have a qualified and currently certified administrator. The administrator... shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section...The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.

This requirement is not met as evidenced by:
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Administrator agreed to submit to licensing the pending application received by CAB and submit an LIC308 to CCLD by POC due date.
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Based on interview, the licensee did not comply with the section cited above in by not having a certified administrator on the premises at sufficient number of hours to fulfill responsibilities including but not limited to management and administration during the day hours which poses a potential health, safety or personal rights risk to persons in care.
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Licensee provided proof of RCFE 80 hour certification course passed and USPS of mailing application. Pending applicant not showing in CAB system.

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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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2026


LIC809 (FAS) - (06/04)
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