079201013-4-30-2024-15-AS-HHUL-D6TLVQ-20240703090551

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201013
Report Date: 04/30/2024
Date Signed: 04/30/2024 01:38:22 PM

Unsubstantiated

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
06/26/2023 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230626095517

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:	04/30/2024
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Diosdado Savellano, Caregiver		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff did not meet resident's personal needs on the weekends

INVESTIGATION FINDINGS:

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On 4/30/2024 at 10:15AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and to deliver complaint findings for the allegation above. LPA met with Caregiver, Diosdado Savellano and explained the purpose of the visit.

During the investigation, LPA interviewed 3 residents, staff, witness, and complainant. LPA reviewed and obtained documents including staff roster with phone numbers, physician's report, and care plan. Interview with residents and witness revealed there's usually 1-2 caregivers on the weekends and staff assist with ADL care. R3 stated that staff provides care and R3's needs are being met.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore these allegation is UNSUBSTANTIATED.

No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

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

LIC9099 (FAS) - (06/04)

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