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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200827
Report Date: 05/21/2021
Date Signed: 05/21/2021 04:55:57 PM

Document Has Been Signed on 05/21/2021 04:55 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:LOVING HANDS CARE HOME LLCFACILITY NUMBER:
079200827
ADMINISTRATOR:SAN DIEGO-TOMAS, CECILIAFACILITY TYPE:
740
ADDRESS:748 VAQUEROS AVETELEPHONE:
(510) 245-3738
CITY:RODEOSTATE: CAZIP CODE:
94572
CAPACITY: 6CENSUS: 3DATE:
05/21/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Mauricio David, CaregiverTIME COMPLETED:
05:10 PM
NARRATIVE
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On 5/21/2021 at 4:30PM, Licensing Program Analysts (LPAs) G. Luk and L. Hall arrived unannounced to conduct a case management inspection. LPAs met with care staff, Mauricio David.

When LPA G. Luk open complaint (15-AS-20210302091640) on 3/11/2021, it was observed that R2 had a full bed rail and was not on hospice care.

At 4:25PM, LPAs observed medication cabinet was unlocked. Caregiver locked cabinet after LPAs reminded him.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/21/2021 04:55 PM - It Cannot Be Edited


Created By: Grace Luk On 05/21/2021 at 04:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LOVING HANDS CARE HOME LLC
FACILITY NUMBER: 079200827

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/24/2021
Section Cited
CCR
87608(a)(5)(B)

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Postural Supports. Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care... This requirement is not met as evidence by:
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Administrator has agreed to removed the full bed rail and provide picture proof by POC date.
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Based on investigation, licensee did not comply with the section cited above by having a full bed rail for a non-hospice resident which poses an immediate health and safety risk to the residents in care.
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Type A
05/22/2021
Section Cited
CCR87465(h)(2)

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Incidental Medical and Dental Care. Centrally stored medicines shall be kept in a safe and locked place that is not accessible...
This requirement is not met as evidence by:
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Caregiver locked the medication cabinet during visit.

Deficiency cleared during inspection
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Based on observation, licensee did not comply with the section cited above by not locking the medication cabinet which poses an immediate health and safety risk to the 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2021


LIC809 (FAS) - (06/04)
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