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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201013
Report Date: 04/30/2024
Date Signed: 04/30/2024 01:39:17 PM


Document Has Been Signed on 04/30/2024 01:39 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:
04/30/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Diosdado Savellano, CaregiverTIME COMPLETED:
01:50 PM
NARRATIVE
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On 4/30/2024 at 12:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Caregiver, Diosdado Savellano and explained the purpose for the visit.

While LPA G. Luk was at the facility for a complaint investigation (#15-AS-20230626095517), the following deficiency was observed.

After reviewing Guardian system, LPA G. Luk observed staff (S1) was not fingerprint cleared or associated to the facility. LPA spoke with House Manager, Monique Robinson over the phone and informed her that S1 cannot be at the facility until fingerprint clearance is completed. LPA observed S1 left the facility during visit.

Civil penalty of $3,000 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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/30/2024 01:39 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: 04/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
05/01/2024
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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S1 left the facility during visit. Facility has agreed to contact Guardian regarding S1's fingerprint clearance and submit communication to CCLD by POC date.
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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 $3,000 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024
LIC809 (FAS) - (06/04)
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