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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201013
Report Date: 12/12/2023
Date Signed: 03/22/2024 11:40:29 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
10/31/2023 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20231031133136
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: 6DATE:
12/12/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:House Manager Monique RobinsonTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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9
Staff did not issue a refund to resident's authorized representative
INVESTIGATION FINDINGS:
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13
On 12/12/2023 at 09:00 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to deliver the findings pertaining to the allegation above. Upon arrival, LPA stated the purpose of the visit to Caregiver Leonila "Dess" Savellano and spoke to House Manager Monique Robinson over the phone at approximately 9:20 AM.

The complaint alleges that staff did not issue a refund to resident's authorized representative.
Review of facility records and interviews of House Manager Monique Robinson and Licensee/Administrator Sabrina Crowder revealed that resident R1 was transferred by their authorized representative to another facility without a 30-day notice, so they do not qualify for a refund.

Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove it; therefore, the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report was provided via email.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
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 4
Control Number 15-AS-20231031133136
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
CCR
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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 HumpalTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
10/31/2023 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20231031133136

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: 6DATE:
12/12/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Caregiver Leonila "Dess" SavellanoTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not meet resident's medical needs
Staff did not notify resident's authorized representatives of incident
Staff do not answer phone calls
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/12/2023 at 09:00 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to deliver the findings pertaining to the allegations above. Upon arrival, LPA stated the purpose of the visit to Caregiver Leonila "Dess" Savellano and spoke to House Manager Monique Robinson over the phone at approximately 9:20 AM.

The complaint alleges that staff did not meet resident's medical needs. During his review of the records and interviews of House Manager Monique Robinson and Licensee/Administrator Sabrina Crowder on 11/15/2023, the LPA observed that the medical needs of R1 were being met in accordance with Title 22 Regulations.

The complaint alleges that staff did not notify resident's authorized representatives of incident. During his review of the records on 11/15/2023, the LPA observed text message documentation between House Manager Monique Robinson and Witness 2 (W2) that the representative W2 had been notified of the incident on 02/21/2023.

(Continued on LIC9099-C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20231031133136
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ASK: HIDDEN VALLEY CARE HOME
FACILITY NUMBER: 079201013
VISIT DATE: 12/12/2023
NARRATIVE
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(...Continued from LIC9099-A)

The complaint alleges that staff did not answer phone calls. On 11/03/2023 at 12:41 PM, The LPA called into the facility and his call was answered promptly. On 12/12/2023, phone interviews of Responsible Parties W3 and W6 about their experience of calling into the facility was that their calls were answered promptly.

Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove them; therefore, the allegations are UNSUBSTANTIATED.

Exit interview conducted with the HM and a copy of this report was provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4