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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200744
Report Date: 09/14/2022
Date Signed: 09/14/2022 04:56:47 PM


Document Has Been Signed on 09/14/2022 04:56 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:SACRED HANDS LIVINGFACILITY NUMBER:
019200744
ADMINISTRATOR:PANESAR, RAJWANTFACILITY TYPE:
740
ADDRESS:2980 BLUMEN AVETELEPHONE:
(925) 392-8652
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 3DATE:
09/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:01 PM
MET WITH:Rajwant Panasar, AdministratorTIME COMPLETED:
05:20 PM
NARRATIVE
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On 9/14/2022 Licensing Program Analysts (LPAs) Leslie Ibo and Liridon Fici conducted unannounced case management visit while conducting a complaint investigation. LPAs was greeted by care staff (S3) and explained the purpose of the visit. LPAs called Administrator (ADM) Raj and explained the purpose of the visit. At 12:33 PM, ADM arrived at the facility and met with LPAs. LPA’s toured the facility inside and outside.

LPAs observed the following:

· At 10:51AM LPA observed unlocked chemicals at the laundry room that are accessible to residents in care.
· During the course of complaint interview, LPAs found out that Administrator (ADM) did not report incident that happened at the facility

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Rajwant Panasar.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 09/14/2022 04:56 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: SACRED HANDS LIVING
FACILITY NUMBER: 019200744

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2022
Section Cited

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Care of persons with Dementia: (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances...

This requirement is not met as evidence by:
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Based on observation, the licensee did not comply with the section cited above by having Lysol accessible to residents in care located in the unlocked laundry room , which poses a immediate health and safety risk for persons in care.
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Administrator agreed to conduct in-service training for all the staff regarding the citation cited.
A copy of training with staff name and signature is needed to be submitted to CCL office by 9/19/2022.
Type B
09/19/2022
Section Cited

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Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require...
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events...
This requirement is not met as evidence by:
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Based on interview and record review, the licensee did not comply with the section cited above by not submitting incident reports to CCL within seven days, which poses a potential health and safety risk for persons in care.
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A copy of training with staff name and signature is needed to be submitted to CCL office by 9/19/2022.
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: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2