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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200770
Report Date: 11/28/2020
Date Signed: 11/28/2020 11:42:31 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:ASK ASSISTED LIVING LLCFACILITY NUMBER:
079200770
ADMINISTRATOR:CROWDER, MARKFACILITY TYPE:
740
ADDRESS:3414 DEER HILL RDTELEPHONE:
(510) 682-8409
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY:6CENSUS: 6DATE:
11/28/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Sabrina Crowder, AdminstratorTIME COMPLETED:
11:00 AM
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On 11/28/20 at 10:20AM, LPA D Panlilio conducted a case management phone discussion with Administrator regarding the incident on 11/24/20 wherein an Ombudsman was not initially allowed to enter the facility to check on her residents. Administrator was not physically available to sign this report due to COVID-19 shelter in place order.

LPA explained to Administrator that under PIN-20-23-ASC, visitations are permitted to allow essential workers such as CDSS, CDPH, Ombudsman, local health department officials, hospice healthcare providers and essential government authorities to enter or conduct investigations/visits at the facility.

Administrator told LPA that she eventually allowed the Ombudsman to enter her facility on the same day,11/24/20, to check on her residents after the visitation limits exceptions were clarified under PIN-20-23-ASC by LPA and Ombudsman. Administrator agreed to comply with the visitation policies as outlined in PIN-20-23-ASC.

Exit interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Rajind BasiTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2020
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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