079201013-2-17-2023-15-AS-KHOS-CPAU6T-20230222141852

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201013
Report Date: 02/17/2023
Date Signed: 02/17/2023 02:41:18 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2023 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230210155122

FACILITY NAME:	ASK: HIDDEN VALLEY CARE HOME		FACILITY NUMBER:	079201013
ADMINISTRATOR:	SABRINA P. CROWDER		FACILITY TYPE:	740
ADDRESS:	33 HIDDEN VALLEY ROAD		TELEPHONE:	(925) 289-9134
CITY:	LAFAYETTE	STATE: CA	ZIP CODE:	94549
CAPACITY:	6	CENSUS: 5	DATE:	02/17/2023
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Leonila Teresita Savellano, Care Staff		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility failed to issue a refund

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 2/17/2023 at 2:15 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to deliver findings for the above allegation. Upon arrival, LPA met with Care Staff, Leonila Teresita Savellano and explained the purpose of the visit. LPA spoke to Administrator, Monique Robinson over the phone.

During the course of the investigation, LPA obtained information, reviewed records, collected documents and interviewed S1 and F1. It was alleged facility failed to issue a refund. Based on information obtained by complainant, when a refund was requested after removing R1's personal property out of the facility, facility refused to issue the refund.

REPORT CONTINUES ON 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 15-AS-20230210155122

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: HIDDEN VALLEY CARE HOME	FACILITY NUMBER: 079201013
	VISIT DATE: 02/17/2023

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
26
27
28
29
30
31
32

Interview with S1 revealed R1's personal property was removed on 8/16/2022 and that the facility has not issued a refund because F1 has not returned the facility's call to verify the mailing address. However, F1 denied receiving a voicemail.

On 2/17/2023, LPA was informed by S1 that a check of $4,646 is being mailed to R1's responsible party.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted over the phone with Administrator, Monique Robinson. Administrator authorized Care Staff to sign report.

Appeal Rights and a copy of this report provided to Care Staff.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20230210155122

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: HIDDEN VALLEY CARE HOME	FACILITY NUMBER: 079201013
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/17/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/24/2023 Section Cited CCR 1569.652(c)	1 2 3 4 5 6 7	1569.652(c) TERMINATION OF ADMISSION AGREEMENT UPON DEATH.. (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility... if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed.	1 2 3 4 5 6 7	By POC date, Administrator will submit a proof of refund, In addition, Administrator will review regulation and submit a self-certification letter of understanding to CCLD.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interview and record review, Licensee did not comply with the regulation cited above by not issuing a refund to R1's responsible party within 15 days after R1's personal property was removed on 8/16/22 which poses a potential personal rights to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3