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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200816
Report Date: 04/08/2022
Date Signed: 04/08/2022 04:06:36 PM

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
01/20/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220120081118
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: 3DATE:
04/08/2022
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Rajwant Panesar, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident sustained pressure injury while in care
Resident did not get medical attention in a timely manner
INVESTIGATION FINDINGS:
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On 04/08/22 at 2:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit and met with administrator to deliver the findings of above allegations. LPA explained the purpose of the visit with administrator.

Allegation: Resident sustained pressure injury while in care
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews, resident (R1) was first admitted at the facility on 12/21/2021 where administrator observed R1 only had one stage two pressure injury to his lower back. Home Health RN who performed the initial assessment for R1 at the facility remembered seeing a “small stage 2” pressure injury on R1’s buttocks. She did not remember seeing any other pressure injuries on R1 during her initial assessment. Review of hospital records dated 01/21/22 show R1 had 5 unstageable pressure injuries with photos taken shortly after R1’s arrival to the emergency room of the hospital on 01/18/22. R1 was found to have a “stage 4” or “unstageable” wound on his lower back and had 3 other different sores all in different signs of healing on his right hip. Administrator confirmed with investigator that R1’s various pressure injuries occurred while in care at the facility. The preponderance of evidence has been met. Therefore, this allegation is substantiated.

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: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
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 3
Control Number 15-AS-20220120081118
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: 04/08/2022
NARRATIVE
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Allegation: Resident did not get medical attention in a timely manner
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews, the facility did not seek medical attention in a timely manner for resident (R1). Despite home health nurse’s recommendation on 01/14/22 to immediately transport resident (R1) to the hospital due to visual signs of R1’s altered baseline/acute changes in mental status/suspected fever (hot to the touch) and Hypoxia (low blood oxygen level). Both authorized representative (POA) and administrator refused to transport R1 to the hospital on 01/14/22. Administrator stated to investigator that R1 was just “tired and dehydrated”. R1 was finally transported to the hospital on 01/18/22 where he was admitted and diagnosed with urinary tract infection and sacral wounds. The preponderance of evidence has been met. Thus, this allegation is substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due date and/or any 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: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20220120081118
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: 04/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/09/2022
Section Cited
CCR
87465(a)(1)
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The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents..
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Immediate civil penalty of $500 assessed during visit.
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This requirement was not met as evidenced by resident sustaining pressure injuries while in care which posed an immediate health & safety risk to resident.
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By POC due date, administrator agrees to conduct in-service staff retraining on proper care and supervision of residents and will submit to CCLD copy of completed staff retraining.
Type A
04/09/2022
Section Cited
CCR
87465(g)
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The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis…
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By POC due date, Administrator agrees to submit to CCLD completed in-service staff retraining on following proper emergency protocol to ensure residents’ health needs are met in a timely manner.
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This requirement was not met as evidenced by resident not getting medical attention in a timely manner which posed an immediate health & safety risk to the resident
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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: 04/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3