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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 11:56:15 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Sabrina Patterson, Administrator/ApplicantTIME COMPLETED:
11:43 AM
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On 11/13/20 at 11AM, while conducting a Face time tele visit Pre licensing with applicant Sabrina Patterson, LPA completed the component III presentation during the inspection.
Applicant was not physically available to sign this report due to COVID-19 shelter in place.

LPA observed the facility had the necessary COVID-19 signage and posters in place. Hallway bulletin board had CCLD complaint poster, LTCO poster, Residents' rights and rights to council, Emergency/Disaster Plan (LIC 610E), Designation of Facility responsibility (LIC 308), facility exit plan. Common areas such as front entrance, hallways and bathrooms had COVID-19 signage displayed. Front entrance had a small side table containing hand sanitizer, no touch temperature probe, gloves, face masks. shoe covers and visitor's log. Staff and visitors are screened prior to entry into the facility.

LPA discussed the common deficiencies of facility operation with applicant and how to address/resolve them.

No issues noted during the pre-licensing inspection. LPA observed the facility is ready to be licensed. However, this report will be submitted to the central application unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
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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