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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601073
Report Date: 10/28/2020
Date Signed: 10/28/2020 11:04:58 AM

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:HIDDEN VALLEY CARE HOMEFACILITY NUMBER:
075601073
ADMINISTRATOR:NAVEEN SHARMAFACILITY TYPE:
740
ADDRESS:33 HIDDEN VALLEY ROADTELEPHONE:
(925) 284-5201
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY:6CENSUS: 5DATE:
10/28/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Imelda Malleta, CaregiverTIME COMPLETED:
11:30 AM
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On Wednesday, October 28, 2020 at 10:00 AM, Licensing Program Analyst (LPA) C. Phomphachanh arrived unannounced to a conduct a health and safety visit. LPA met with Caregivers, Imelda Malleta and Eduardo Tabones. LPA explained reason of the visit due to no contact while Emergency Disaster Team was trying to reach out to the facility during the power shut off. This is a two story Residential Care Facility for the Elderly. There are 6 rooms and currently 5 residents.

LPA toured the facility with Caregiver, Imelda Malleta, not limited to living room, dining room, residents' rooms, kitchen, garage, bathrooms, and front/back yard. No bodies of water or obstruction of walkways/doorways. There are sufficient 3-day perishable and 7-day nonperishable food supplies on hand. Sharp objects are locked in cabinets in the kitchen. Medications are locked in a cabinet near the dining area. There are sufficient linens and hygiene supplies on hand. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date.

LPA conducted wellness check and COVID-19 consultation. Posters and signs visible. Facility is following COVID-19 protocol guidelines within the Department of Public Health. PPE supply is limited.

No deficiencies cited during the health and safety check. Exit interview conducted with Caregiver, Imelda Malleta and a copy of this report will be emailed to Administrator, Joyv Ignastius
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020
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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