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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200744
Report Date: 12/07/2021
Date Signed: 12/07/2021 11:47:18 AM

Unsubstantiated


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
04/08/2020 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200408083147
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:
12/07/2021
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Rajwant Panesar, AdministratorTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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Facility staff did not notice a change in the resident's condition
Facility staff did not seek medical attention in a timely manner
Facility staff did not provide resident's records to emergency medical personnel
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. According to 2 of 2 staff, residents are observed every couple of hours. S1 stated in April 2020, R1 was exhibiting an increase in behavioral issue, so facility called 9-1-1. According to S1, R1 is not diabetic. Upon EMS arrival, EMS requested a copy of R1's POLST sheet. However, since it was the only copy facility had, S1 suggested for EMS to take a photo of POLST sheet and according to S1, EMS agreed.

REPORT CONTINUES ON 9099C

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (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 2
Control Number 15-AS-20200408083147
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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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 this report is provided via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (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: 2 of 2