019200744-10-11-2021-15-AS-KHOS-C7XR2B-20211019123804

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200744
Report Date: 10/11/2021
Date Signed: 10/11/2021 04:54:47 PM

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
02/26/2021 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20210226085526

FACILITY NAME:	SACRED HANDS LIVING		FACILITY NUMBER:	019200744
ADMINISTRATOR:	PANESAR, RAJWANT		FACILITY TYPE:	740
ADDRESS:	2980 BLUMEN AVE		TELEPHONE:	(925) 392-8652
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	6	CENSUS: 5	DATE:	10/11/2021
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Rajwant Panesar		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Licensee did not assist resident with medications as needed.

INVESTIGATION FINDINGS:

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On 10/11/2021 Licensing Program Analyst (LPA) L.Ibo conducted unannounced visit to deliver findings on the above allegations. LPA spoke with Administrator, Rajwant Panesar.

During the course of the investigation, LPA interviewed staff (S1-S2) and residents (R1, R3, R5). In addition, LPA conduct facility tour inside and outside.

LPA conducted records review, based on Medication Administration (MAR) there are days that signature spot left blank without documentation of reason why the MAR was blank, LPA interviewed S1 and she was not sure if staff gave those medication or intentionally left the MAR. LPA interviewed S2 and, and she said the staff might forgot to document or did not give the medication. The above-mentioned allegation is deemed substantiated.
...Continue to LIC 9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021

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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Control Number 15-AS-20210226085526

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SACRED HANDS LIVING	FACILITY NUMBER: 019200744
	VISIT DATE: 10/11/2021

NARRATIVE

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A finding that the complaint is substantiated means that the allegation are valid because the preponderance of the evidence standard has been met.

The following deficiencies was observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview was conducted. Appeal rights was given

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20210226085526

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SACRED HANDS LIVING	FACILITY NUMBER: 019200744
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/11/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/22/2021 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	INCIDENTAL MEDICAL AND DENTAL CARE (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Adminsitrator needs to conduct in-service training for all staff regarding the regulation that was cited from, proof of training need to be submitted to CCL office by POC date.
	8 9 10 11 12 13 14	Based on records review, licensee did not comply with regulation above, there are blank signature page on Medication Administration record (MAR) log and S1 & S2 is not sure if medications were given to residents in care, this is pottential health risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021

LIC9099 (FAS) - (06/04)

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