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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200816
Report Date: 11/04/2021
Date Signed: 11/04/2021 07:19:58 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
12/08/2020 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20201208114253
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
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Rajwant Panesar, AdministratorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Staff mismanages residents' medication
Medical assessment was not done on resident
Food services are inadequate
INVESTIGATION FINDINGS:
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On 11/04/21 at 4:30PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a subsequent complaint visit and met with administrator (ADM) to deliver the investigation findings. LPA explained the purpose of the visit with ADM.

Allegation: Staff Mismanages Residents’ Medication
Investigation Finding: Substantiated
Upon records review, the Department found that R1s medication records were inadequate and the medication list provided by the Reporting Party did not match the Centrally Stored Medication record. The facility also did not have the MD medication order.

Allegation: Medical Assessment was not done on Resident
Investigation Finding: Substantiated
Upon records review, the Department found that the facility had failed to obtain a required Medical Assessment by a physician.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 15-AS-20201208114253
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 II
FACILITY NUMBER: 079200816
VISIT DATE: 11/04/2021
NARRATIVE
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Allegation: Food Services are Inadequate
Investigation Finding: Substantiated

Upon investigation, the Department was informed by the Licensee that food supplies are obtained every Monday; however, neutral witnesses who had visited the facility in an official capacity performed an evaluation on 12/16/20 (a Wednesday) and observed that there was an inadequate amount of fresh fruit and vegetables to meet the requirement of 2 days of perishable foods for the number of residents in care at that time.

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.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20201208114253
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 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
CCR
87465(e)
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For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information...
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By POC date, administrator agreed to self certify that all residents' centrally stored records match their doctors' orders and submit copies to CCLD.
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This requirement was not met as evidenced by R1's medical records not matching the centrally stored logs which posed a potential health & safety risk to residents in care.
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Type B
11/29/2021
Section Cited
CCR
87458(a)
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Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year...
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By POC date, administrator agreed to self certify that she has read, understood and will comply with Title 22 Section 87458 Medical Assessment.
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This requirement was not met as evidenced by facility failing to secure a medical assessment for R1 prior to admission 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
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20201208114253
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 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
CCR
87555(b)(26)
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(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises...
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By POC date, administrator agreed to self certify that she has read, understoon and will comply with Title 22 Section 87555 General Food Service Requirements.
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This requirement was not met as evidenced by insufficient food supplies at the facility 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
LIC9099 (FAS) - (06/04)
Page: 4 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
12/08/2020 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20201208114253

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
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Rajinder Panesar, AdministratorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Facility is malodorous
Resident's toileting needs not being met
Resident's bathing needs not being met
Untrained staff
Facility kitchen equipment is in disrepair
INVESTIGATION FINDINGS:
1
2
3
4
5
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7
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On 11/04/21 at 4:30PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a subsequent complaint visit and met with administrator (ADM) to deliver the investigation findings. LPA explained the purpose of the visit with ADM.

Allegation: Facility is Malodorous
Investigation Finding: Unsubstantiated
The Reporting Party asserted having visited R1 and that R1s room smelled of human waste; the facility asserted that R1 exhibited a behavior that resulted in times where the staff needed to clean down R1s room. Neutral witnesses reported having visited the facility on multiple occasions during the subject time period and stated that they detected no unusual odors. Information obtained was insufficient to determine if there had been chronic odors during the subject time period, or that the room and/or facility exhibited odors due to insufficient housekeeping.

Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20201208114253
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 II
FACILITY NUMBER: 079200816
VISIT DATE: 11/04/2021
NARRATIVE
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Allegation: Resident’s toileting needs are not being met
Investigation Finding: Unsubstantiated

The Reporting Party asserted that R1 was not being assisted with her toileting needs. The Department found that the facility had failed to develop a required Appraisal Needs and Services report to ascertain the toileting needs that R1 may or may not have needed based upon her capability. Although it was not possible to determine whether R1 required toileting assistance that was not being provided, the facility is cited under a Case Management report dated 11/04/21.

Allegation: Resident’s bathing needs are not being met


Investigation Finding: Unsubstantiated

The Reporting Party asserted that R1 was not being assisted with her bathing needs. The Department found that the facility had failed to develop a required Appraisal Needs and Services report to ascertain the bathing needs that R1 may or may not have needed based upon her capability. Although it was not possible to determine whether R1 required bathing assistance that was not being provided, the facility is cited under a Case Management report dated 11/04/21.

Allegation: Untrained Staff


Investigation Finding: Unsubstantiated

The Department found that the staff that were scheduled during the subject time period had the records from an acceptable training organization reflecting the required subjects and hours required. However, per 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 and is cited under a Case Management report dated 11/04/21

Allegation: Facility Kitchen Equipment is in Disrepair


Investigation Finding: Unsubstantiated

The Department found that the facility’s stove became inoperable and that the facility addressed the situation in a timely fashion. The Licensee contacted PG&E, who reported to the facility on 12/1/20 and disconnected the unit. Receipts illustrated that on the same day the facility purchased a new stove but that there was an installation delay due to the COVID pandemic; however, it was installed on 12/18/21. Neutral witnesses who had visited the facility on multiple occasions during the subject time period reported that they were aware of the status of the stove but observed that the facility had an alternate means of preparing hot food and the residents were provided with three meals per day. The neutral witnesses had no concerns regarding the meals provided.

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

Exit Interview conducted and a copy of this report provided to Administrator. erns regarding the meals provided.

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
LIC9099 (FAS) - (06/04)
Page: 6 of 6