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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201013
Report Date: 07/18/2023
Date Signed: 07/18/2023 12:27:50 PM


Document Has Been Signed on 07/18/2023 12:27 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: HIDDEN VALLEY CARE HOMEFACILITY NUMBER:
079201013
ADMINISTRATOR:SABRINA P. CROWDERFACILITY TYPE:
740
ADDRESS:33 HIDDEN VALLEY ROADTELEPHONE:
(925) 289-9134
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY:6CENSUS: 5DATE:
07/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Monique Robinson, House ManagerTIME COMPLETED:
12:40 PM
NARRATIVE
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On 7/18/2023 at 11:00AM, Licensing Program Analysts (LPAs) G. Luk and K. Nguyen arrived unannounced to conduct a case management visit. LPAs met with Caregiver, Leonila Savellano and explained the purpose for the visit. House Manager, Monique Robinson arrived 30 minutes later.

On 7/2/2023, while LPA G. Luk was at the facility for a complaint investigation (#15-AS-20230626095517), the following deficiencies were observed.

After reviewing Guardian system, LPA G. Luk observed two staff (S2 and S3) were not fingerprint cleared or associated to the facility. Additionally, another two staff (S1 and S4) were fingerprint cleared, but not associated to the facility.


The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
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 07/18/2023 12:27 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: HIDDEN VALLEY CARE HOME
FACILITY NUMBER: 079201013

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2023
Section Cited
CCR
87355(e)(1)

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Criminal Record Clearance. All individuals subject to a criminal record review... Obtain a California clearance...as required by the Department... This requirement is not met as evidence by:
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Facility has agreed to obtain fingerprint clearance S3 and S2 will not be a staff at the facility. House manager will submit a plan to obtain fingerprint clearance for S3 by POC date.
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Based on record review, licensee did not comply with the section cited above by not having two staff fingerprint cleared which poses an immediate health and safety risk to the persons in care.
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Civil penalty of $400 is being assess.
Type B
07/25/2023
Section Cited
CCR87355(e)(2)

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Criminal Record Clearance. All individuals subject to a criminal record review...Request a transfer of a criminal record clearance... This requirement is not met as evidence by:
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Facility has agreed to associate S1 and S4 to the facility and submit proof of association by POC date.
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Based on record review, licensee did not comply with the section cited above by not having two staff associated to the facility which poses a potential health and safety risk to the persons in care.
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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2