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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201013
Report Date: 11/13/2020
Date Signed: 11/13/2020 11:42:02 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: HIDDEN VALLEY CARE HOMEFACILITY NUMBER:
079201013
ADMINISTRATOR:CROWDER, MARKFACILITY TYPE:
740
ADDRESS:33 HIDDEN VALLEY ROADTELEPHONE:
(925) 289-9134
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY:6CENSUS: 3DATE:
11/13/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sabrina Patterson, Administrator/applicantTIME COMPLETED:
11:00 AM
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On 11/13/20 at 10AM, Licensing Program Analyst (LPA) D. Panlilio conducted a tele visit pre licensing inspection and met with Administrator/applicant Sabrina Patterson. LPA explained to applicant that this visit is being conducted via Face time in compliance with the shelter in place order of the governor. The facility's fire clearance was approved for 6 non-ambulatory residents including one bedridden in Room# 3. Applicant was not physically available to sign this report due to COVID-19 shelter in place.

During the tele visit inspection, LPA toured the facility with Administrator/applicant including but not limited to the residents' bedrooms, common areas, kitchen, and outdoor area. LPA observed adequate lighting in the house. All three residents were observed relaxing in their rooms. There are designated individual locked storage cabinets for cleaning supplies, knives and medications found in the kitchen. Indoor and outdoor passageways were observed free of obstruction. Smoke and carbon monoxide detectors were observed to be in working condition. First aid kit is complete. LPA observed 3 fire extinguishers fully charged and last inspected on 01/09/20. LPA observed a one week supply of perishable foods and 2 weeks supply of non-perishable foods. Towels, sheets, activity supplies and hygiene products were observed available. The facility has 2 full bathrooms. LPA observed the shower area has non skid floors with shower mats. There are activity materials observed in the activity room. The backyard was observed unobstructed with self latching side gate. There were no bodies of water observed. Facility has flashlights available for emergency use. The facility has an attached garage that has storage cabinets for emergency water and canned goods supplies. Exit auditory signals were operational.

LPA observed that facility has no deficiencies and is ready to be licensed. This report will be submitted to the Central Applications Branch (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

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

DATE: 11/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020
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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