<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200744
Report Date: 10/11/2021
Date Signed: 10/11/2021 04:47:05 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
07/31/2020 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20200731154710
FACILITY NAME:SACRED HANDS LIVINGFACILITY NUMBER:
019200744
ADMINISTRATOR:PANESAR, RAJWANTFACILITY TYPE:
740
ADDRESS:2980 BLUMEN AVETELEPHONE:
(209) 762-2910
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 5DATE:
10/11/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Rajwant PanesarTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not assist resident with hygiene needs
Facility staff did not assist resident with dressing needs
Facility staff did not ensure that resident had clean clothing
Resident was left in soiled bedding for an extended period of time
Facility staff did not provide an adequate amount of food to resident

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 & R4) . In addition, LPA toured the facility inside and outside.

For the allegation, facility staff did not assist resident with hygiene needs, facility staff did not assist resident with dressing needs, facility staff did not ensure that resident had clean clothing, resident was left in soiled bedding for an extended period of time. LPA interviewed 3 current residents at the facility. All 3 residents indicated that their needs are being met, the resident appears to have clean clothing and groomed. Therefore, this allegation is unsubstantiated.
....Continuation on LIC 9099 C ....
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 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)
Page: 1 of 6
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
07/31/2020 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20200731154710

FACILITY NAME:SACRED HANDS LIVINGFACILITY NUMBER:
019200744
ADMINISTRATOR:PANESAR, RAJWANTFACILITY TYPE:
740
ADDRESS:2980 BLUMEN AVETELEPHONE:
(209) 762-2910
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 5DATE:
10/11/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Rajwant PanesarTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not keep the facility clean
Facility staff did not dispense medications as prescribed
Facility did not issue a refund in a timely manner
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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.

For allegation, facility staff did not keep the facility clean, LPA gathered pictures from RP based on the evidence it appeared that facility floor was dusty, there are cereals on the floor, bathroom sink was stained, and dusty, resident closet was unorganized with resident’s clothing on the floor and not folded. The above-mentioned allegation is deemed substantiated.
....Continuation on LIC 9099 C ....
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 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)
Page: 2 of 6
Control Number 15-AS-20200731154710
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
For allegation, facility staff did not dispense medications as prescribed , LPA conducted records review, based on Medication Administration (MAR) there are days that signature spot was 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.

For allegation, facility did not issue a refund in a timely manner – Based on records review and interview the resident’s family paid rent on April 1,2020 , financial responsibility ended on April on April 8,2020 and refund was issued on September 2, 2020, therefore the allegation was substantiated.

A finding that the complaint is substantiated means that the allegations 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 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)
Page: 3 of 6
Control Number 15-AS-20200731154710
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
87303(a)
1
2
3
4
5
6
7
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services...
This evidence is not met as evidence by:
1
2
3
4
5
6
7
Administrator will conduct in-service training for all staff reviewing the regulation that was cited from. Proof of inservice training need to send to LPA on POC date.
8
9
10
11
12
13
14
Based on LPA’s records review, Licensee did not comply with the regulations cited above. LPA gathered pictures from RP based on the evidence it appeared that facility floor was dusty, there are cereals on the floor, bathroom sink was stained, and dusty, resident closet was unorganized with resident’s clothing on the floor and not folded which poses a potential health, safety or personal rights risk to persons in care. which posed a potential Health & Safety risk to residents in care.
8
9
10
11
12
13
14
Type B
10/22/2021
Section Cited
HSC
1569.652(c)
1
2
3
4
5
6
7
Health and Safety Code section 1569.652 provides in part:(c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual...
This evidence is not met as evidence by:
1
2
3
4
5
6
7
Administrator agrees to review regulation and send a self-certification letter to CCL by POC date.
8
9
10
11
12
13
14
Based on record review and interview, Licensee did not comply with the regulations above. R6's personal property was removed on April 8,2020 and a refund was not issued until 9/2/2020 which poses a potential personal rights to residents in care.
8
9
10
11
12
13
14
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: Leslie IboTELEPHONE: 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)
Page: 4 of 6
Control Number 15-AS-20200731154710
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 spot on Medication Administration record 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 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)
Page: 5 of 6
Control Number 15-AS-20200731154710
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
For the allegation, Facility staff did not provide an adequate amount of food to resident facility has pre-schedule breakfast, lunch, and dinner list on a monthly calendar. LPA interviewed 3 current residents, residents did not have any issue on food or is on a special diet. R6 passed away and cannot be interviewed to verify allegation. Therefore, this allegation is unsubstantiated.

Based on interviews conducted and observations, LPA has found these allegations to be UNSUBSTANTIATED.



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

Exit interview conducted with Administrator, Rajwant Panesar, and a copy of report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 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)
Page: 6 of 6