079200770-5-1-2024-15-AS-CFOR-D4UUU3-20240501155252

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200770
Report Date: 05/01/2024
Date Signed: 05/01/2024 03:53:15 PM

Document Has Been Signed on 05/01/2024 03:53 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	ASK ASSISTED LIVING LLC		FACILITY NUMBER:	079200770
ADMINISTRATOR:	SABRINA P. CROWDER		FACILITY TYPE:	740
ADDRESS:	3414 DEER HILL RD		TELEPHONE:	(510) 682-8409
CITY:	LAFAYETTE	STATE: CA	ZIP CODE:	94549
CAPACITY:	6	CENSUS: 6	DATE:	05/01/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	RIZZA BANTIGUE, CARE STAFF		TIME COMPLETED:	04:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 05/01/2024 at 10:20 AM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct Required 1 Year Annual inspection. Upon arrival LPA was greeted by caregiver, Rizza Bantigue. LPA spoke to Sabrina Crowder, on the phone and explained the purpose of the visit. House Manager Monique Robinson will be joining the visit at approximately 1:00PM. The facility’s fire clearance was approved for 5 Non-Ambulatory and 1 Bedridden. LPA toured facility with including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 68 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathrooms were measured 142.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 12/21/2023 . First aid kit was observed to be complete. Emergency disaster drill was last conducted on 06/14/2023 . Report continues on 809 C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

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 05/01/2024 03:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 LLC	FACILITY NUMBER: 079200770
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having the water temperature in the residents bathroom at 142.2 which poses an immediate health and safety risk to persons in care.
	POC Due Date: 05/02/2024
	Plan of Correction
1 2 3 4	Administrator agreed to turn down the water heater and submit a video to CCL by the POC date.

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having fabreeze, Clorox wipes, lighter and knives unlocked which poses an immediate health and safety risk to persons in care.
	POC Due Date: 05/02/2024
	Plan of Correction
1 2 3 4	Administrator agreed to keep all chemicals, knives, Clorox wipes and lighters locked at all times. Staff removed and locked all items. DEFICIENCY CLEARED DURING VISIT.

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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC809 (FAS) - (06/04)

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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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ASK ASSISTED LIVING LLC	FACILITY NUMBER: 079200770
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having the kitchen and dining room floors in disrepair which poses a potential health and safety risk to persons in care.
	POC Due Date: 06/03/2024
	Plan of Correction
1 2 3 4	Administrator agreed to have the floors repaired or replaced and submit photos to CCL by POC date

Type B

Section Cited

CCR

87307(d)(2)

Personal Accommodations and Services

(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having fence located in the back and side yard in disrepair planks missing and fence leaning which poses a potential health and safety risk to persons in care.
	POC Due Date: 07/01/2024
	Plan of Correction
1 2 3 4	Administrator agreed to repair or replace the fence and submit photos to CCL by the POC date.

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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/01/2024 03:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 LLC	FACILITY NUMBER: 079200770
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87308(c)

Resident and Support Services

(c) General storage space shall be maintained for equipment and supplies as necessary to ensure that space used to meet other requirements of these regulations is not also used for storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by using residents bedroom closets, behind the sectional, in the hallway and residents bathroom, in front of the treadmill, on the side of the TV. stand and in the dining area for storage which poses a potential health and safety or risk to persons in care.
	POC Due Date: 06/21/2024
	Plan of Correction
1 2 3 4	Administrator agreed to remove all the storage and get a storage unit/shed or remove the items from the facility and submit photos to CCL by the POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC809 (FAS) - (06/04)

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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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ASK ASSISTED LIVING LLC	FACILITY NUMBER: 079200770
	VISIT DATE: 05/01/2024

NARRATIVE

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Continue from LIC 809

LPA reviewed 3 of 6 residents records. LPA reviewed 4 of 5 staff records and of 4 have first aid training and associated to the facility. LPA reviewed a sample of 6 of 6 resident’s medications.

LPA observed the following deficiencies:

· At 10:30am, LPA observed S2 is not associated to the facility nor finger print cleared.
· At 10:39am, LPA observed kitchen and dining room floor buckling.
· At 10:51am, LPA observed fabreeze in an unlocked cabinet located in the hallway.
· At 11:08am, LPA observed knives, scissors and lighter in a unlocked drawer located in the kitchen.
· At 11:10am, LPA observed medication in an unlocked drawer located in the kitchen.
· At 11:13am, LPA observed hot water temperature at 142.2 degrees F.
· At 11:22am, LPA observed screen door large box, bed frames and rails, washing machine, mattress pads located in the back and side yard.
· At 11:23am, LPA observed the fence located in the back yard has planks missing and on both sides fence is leaning.
· At 11:31am, LPA observed facility using residents closets for storage, mattresses and boxes behind the sectional in the common area, the hallway and resident bathroom.

Continue on LIC 809C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC809 (FAS) - (06/04)

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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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ASK ASSISTED LIVING LLC	FACILITY NUMBER: 079200770
	VISIT DATE: 05/01/2024

NARRATIVE

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Continue from LIC 809C

LPA requested the following documents to be submitted to CCLD by 5/10/2024.

· Resident Roster
· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 pages)
· Liability Insurance

Copy of Current Administrator Certificate

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

*An immediate $100.00 civil penalty will be assessed on today's date for associations.*

Exit interview conducted. A copy of the LIC421BG, this report and appeal rights provided

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/01/2024 03:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 LLC	FACILITY NUMBER: 079200770
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1)Obtain a California clearance or a criminal record exemption as required by the Department... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not having a Fingerprint Clearance/Criminal Record Clearance for S2 which poses an immediate health and safety risk to persons in care.
	POC Due Date: 05/02/2024
	Plan of Correction
1 2 3 4	Administrator agreed to have caregiver finger print cleared and associated to the facility before S2 returns to the facility. Administrator will submit to CCL a copy of Fingerprint/Criminal Record Clearance and association of caregiver to the facility once completed. S2 left the facility while LPA was present. Civil penalty of $100 will be assessed

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC809 (FAS) - (06/04)

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