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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200827
Report Date: 05/21/2021
Date Signed: 05/21/2021 04:55:02 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
03/02/2021 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210302091640
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
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Mauricio David, CaregiverTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff restrained residents in care.
INVESTIGATION FINDINGS:
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On 5/21/2021 at 4:00PM, Licensing Program Analysts (LPAs) G. Luk and L. Hall arrived unannounced to deliver complaint findings for the allegation above. LPAs met with care staff, Mauricio David.

During the investigation, LPA interviewed 2 staff and complainant. LPA obtained and reviewed 3 resident's files including physician's report, care plan, emergency information, and notes from family members. On 3/11/2021, LPA G. Luk observed R1 had a lap belt on with buckle opening in the back of the wheel chair and R2 had full bed rails with a belt tied across the upper bed rails. Interview with staff revealed that R2 was not on hospice care and an exemption request was not submitted to CCLD for the use of lap belts.

Based on LPA information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC 9099D. Exit interview conducted. A copy of this report and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20210302091640
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: 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)(2)
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Postural Supports.
Postural supports shall be fastened or tied in a manner that permits quick release by the resident.
This requirement is not met as evidence by:
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Administrator will retrain all staff on proper use of lap belts. Administrator will submit training materials and staff sign in sheet to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by having lap belt buckled behind the wheel chair 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
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
LIC9099 (FAS) - (06/04)
Page: 2 of 2