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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201013
Report Date: 08/23/2024
Date Signed: 08/23/2024 10:26:31 AM

Document Has Been Signed on 08/23/2024 10:26 AM - 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/
DIRECTOR:		SABRINA P. CROWDERFACILITY TYPE:
740
ADDRESS:33 HIDDEN VALLEY ROADTELEPHONE:
(925) 289-9134
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY: 6CENSUS: 5DATE:
08/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Imelda Malleta, CaregiverTIME VISIT/
INSPECTION COMPLETED:
10:40 AM
NARRATIVE
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On 8/23/2024 at 9:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with caregiver, Imelda Malleta and explained the purpose for the visit. LPA spoke with assistant administrator, Monique Robinson over the phone regarding the reason for the visit and was informed that caregiver can sign the reports.

On 4/30/2024, licensee was cited for staff (S1) not being fingerprint cleared during visit and had been working at the facility. LPA will be re-citing the licensee under the correct regulation code.

Civil penalty of $500 is being assessed.

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

Exit interview conducted. A copy of this report, civil penalty, and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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 08/23/2024 10:26 AM - It Cannot Be Edited


Created By: Grace Luk On 08/23/2024 at 10:15 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
08/24/2024
Section Cited

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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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Based on record review, licensee did not comply with the section cited above by not having staff fingerprint cleared which poses an immediate health and safety risk to the persons in care.
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Civil penalty of $500 is being assess.

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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 Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024


LIC809 (FAS) - (06/04)
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