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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200816
Report Date: 11/04/2021
Date Signed: 11/04/2021 07:13:38 PM

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 LIVING IIFACILITY NUMBER:
079200816
ADMINISTRATOR:PANESAR, RAJWANT KFACILITY TYPE:
740
ADDRESS:3760 PINTAIL DRTELEPHONE:
(209) 762-2910
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:6CENSUS: 4DATE:
11/04/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
06:19 PM
MET WITH:Rajwant Panesar, AdministratorTIME COMPLETED:
07:20 PM
NARRATIVE
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On 11/04/21 at 6:19PM, while at the facility for another reason, Licensing Program Analyst (LPA) Daisy Panlilio observed the following deficiencies :

· Failure of facility staff to develop R1’s appraisal needs and services plan (for toileting and bathing) prior to resident’s admission on 11/01/2020.

· Staff competency - interview with staff, adequate competency and understanding of dementia care was not exhibited. Although the facility produced adequate records of staff training, the facility failed to ensure staff competency.

· Insufficient staff for the current period – Review of R3’s needs & Services plan require full staff assistance when experiencing effects of Parkinson’s disease. Review of R4’s Physician’s report show R4 require staff assistance and monitoring due to frail physical health condition and old age. Residents currently in care require there be more than 1 staff person present at the facility to ensure residents’ proper care and supervision.

· Failure to address changes in resident’s physical, mental, emotional and social functioning needs. LPA observed R2 and R4’s physicians reports were more than a year old dated 10/15/2019 and 06/15/2019 respectively.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.



Exit interview conducted. Appeal Rights and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
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 3
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 II
FACILITY NUMBER: 079200816
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2021
Section Cited

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Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455...
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This requirement was not met as evidenced by failure of staff to complete a needs/services/appraisal for R1prior to admission which posed a potential health & safety risk to resident in care
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Type B
11/29/2021
Section Cited

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(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs...
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This requirement was not met as evidenced by staff not exhibiting understanding of providing proper dementia care which posed a potential health & safety risk to residents in care
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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 II
FACILITY NUMBER: 079200816
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2021
Section Cited

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There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal...
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This requirement was not met as evidenced by insufficient staff to meet the needs of current residents which posed a potential health & safety risk to residents in care
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Type B
11/29/2021
Section Cited

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The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs...
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This requirement was not met as evidenced by R2 and R4’s physicians reports were more than a year old dated 10/15/2019 and 06/15/2019 which posed a potential health & safety risk to residents in care.
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3