019200744-12-7-2021-15-AS-HHUL-CERPGY-20220525111908

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200744
Report Date: 12/07/2021
Date Signed: 12/07/2021 11:51:02 AM

Substantiated

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
04/22/2020 and conducted by Evaluator Lizette Francisco

COMPLAINT CONTROL NUMBER: 15-AS-20200422152439

FACILITY NAME:	SACRED HANDS LIVING		FACILITY NUMBER:	019200744
ADMINISTRATOR:	PANESAR, RAJWANT		FACILITY TYPE:	740
ADDRESS:	2980 BLUMEN AVE		TELEPHONE:	(209) 762-2910
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	6	CENSUS:	DATE:	12/07/2021
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:			TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Staff failed to keep an accurate medication log

INVESTIGATION FINDINGS:

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On 12/7/2021 starting at 9:50 AM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to deliver findings for the above allegation. Upon arrival, LPA was greeted by Care Staff, Amanda Lopez. Administrator, Rajwant Panesar later arrived at 9:15 AM.

During the course of the investigation, LPA obtained information, collected documents, toured facility, interviewed 2 staff and 2 residents. During record review, LPA observed R2 and R3’s Medication Administration Record is incomplete. Based on interview with S1, medications were administered to the residents on 10/6/21 and 10/7/21. However, staff did not initial MAR.

REPORT CONTINUES ON 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021

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 5

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
04/22/2020 and conducted by Evaluator Lizette Francisco

COMPLAINT CONTROL NUMBER: 15-AS-20200422152439

FACILITY NAME:	SACRED HANDS LIVING		FACILITY NUMBER:	019200744
ADMINISTRATOR:	PANESAR, RAJWANT		FACILITY TYPE:	740
ADDRESS:	2980 BLUMEN AVE		TELEPHONE:	(209) 762-2910
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	6	CENSUS: 5	DATE:	12/07/2021
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Rajwant Panesar, Administrator		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Staff left resident in soiled clothing
Staff took an inappropriate photo of resident

INVESTIGATION FINDINGS:

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On 12/7/2021 starting at 9:50 AM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to deliver findings for the above allegation. Upon arrival, LPA was greeted by Care Staff, Amanda Lopez. Administrator, Rajwant Panesar later arrived at 9:15 AM.

During the course of the investigation, LPA obtained information, collected documents, toured facility, interviewed 2 staff and 2 residents. Based on information obtained, staff left a resident in soiled clothing. However, 2 of 2 staff and 2 of 2 residents stated staff checks on residents every 2 to 3 hours. R2 and R3 are able to use the bathroom independently. It was alleged staff took an inappropriate photo of resident. However, 2 of 2 residents stated staff does not take inappropriate photos of them.

REPORT CONTINUES ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021

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 5

Control Number 15-AS-20200422152439

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: 12/07/2021

NARRATIVE

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During an interview with S1, LPA discovered that when R1 was throwing items around, S1 took a picture to provide “proof” to responsible party of the change of behavior.

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

Exit interview conducted. Due to technical difficulties, a copy of report provided via email.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 15-AS-20200422152439

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: 12/07/2021

NARRATIVE

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Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC9099D.

Exit interview conducted. Due to technical difficulties, Appeal Rights and a copy of this report provided via email.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 15-AS-20200422152439

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: 12/07/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/17/2021 Section Cited CCR 87506(a)	1 2 3 4 5 6 7	87506(a) RESIDENT RECORDS (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff This requirement is not met as evidenced by:	1 2 3 4 5 6 7	By POC date, Administrator will submit proof of training to CCL.
	8 9 10 11 12 13 14	Based on record review and interview, Licensee did not comply with the regulation above. R2 and R3's medication were administered, but staff did not initial MAR which poses a potential health and safety risk to persons 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: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021

LIC9099 (FAS) - (06/04)

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