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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200827
Report Date: 12/06/2024
Date Signed: 12/06/2024 11:40:50 AM

Document Has Been Signed on 12/06/2024 11:40 AM - 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/
DIRECTOR:		SAN DIEGO-TOMAS, CECILIAFACILITY TYPE:
740
ADDRESS:748 VAQUEROS AVETELEPHONE:
(510) 245-3738
CITY:RODEOSTATE: CAZIP CODE:
94572
CAPACITY: 6CENSUS: 3DATE:
12/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:ESTER RAMOS CAREGIVERTIME VISIT/
INSPECTION COMPLETED:
12:54 PM
NARRATIVE
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On 12/6/24 at 9:15AM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to open a 10-day initial complaint on an unrelated matter and conducted a case management. LPA met with Ester Ramos, Caregiver and explained the purpose of the visit.

At 9:55AM, LPA observed S1 was working at the facility and not have done fingerprint clearance. LPA verified that S1 was not fingerprint cleared. LPA was informed that S1 has been working for 2 days.


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

Civil penalty of $200 is being assess.

Exit interview conducted with Cecilia San Diego-Tomas. A copy of this report and appeal rights was provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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 12/06/2024 11:40 AM - It Cannot Be Edited


Created By: Carol Fowler On 12/06/2024 at 11:09 AM
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: 12/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2024
Section Cited
CCR
87355(e)(1)

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All individuals subject to a criminal record review.... shall prior to working, residing or volunteering in a licensed facility: (1) ...the Department. Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to ...transfer of a ...
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Administrator will submit evidence that S1 will not work until criminal record clearance is obtained, proof of criminal record clearance and agree to have all future employee obtain criminal record clearance prior to working at facility and submit to CCL by POC date.

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This requirement is not met as evidenced by: Licensee failed to ensure all staff had a criminal record clearance. LPA observed S1 did not have a criminal record clearance, which poses an immediate safety risk to residents in care.
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A civil penalty of $200 is being assessed today.

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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 Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
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