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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200827
Report Date: 02/01/2023
Date Signed: 02/01/2023 06:10:52 PM


Document Has Been Signed on 02/01/2023 06:10 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: 6DATE:
02/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Princess Nido, caregiverTIME COMPLETED:
06:15 PM
NARRATIVE
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On 2/1/2023 at 3:05PM, Licensing Program Analysts (LPAs) C. Fowler and P. Watson arrived unannounced to conduct an Infection Control Inspection. LPA met with Princess Nido, Caregiver and explained the purpose of the visit.

Upon entry, LPAs temperatures were checked. LPAs observed screening station and COVID-19 signs posted near screening station. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and back yard. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. There is a minimum of 7-day non-perishables and 2-day perishables foods.
During record review, LPA observed facility has a copy of the mitigation plan on file. LPAs observed food and paper supplies are sufficient.

The following deficiencies were observed:
  • At 3:31PM LPAs observed 6 residents with half bed rail without doctors orders.
  • At 3:41PM LPAs observed kitchen cabinet unlocked which contains fabuloso, clorex, lysol and sharps.
  • At 3:44PM LPAs observed 2 unlocked sheds in the backyard.
  • At 3:45PM LPAs observed 3 gates in the backyard locked.
  • At 3:49PM LPAs observed a ladder, bed frame located in the backyard.


Continued on LIC808C.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
VISIT DATE: 02/01/2023
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Continue from 9099
  • At 3:55PM LPAs observed alterations 3 rooms in the garage not on facility sketch.
  • At 4:00PM LPAs observed that resident records for R1, R2, R3, R4, R5 and R6 are not complete.



The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided

The following forms are to be updated and submitted to CCLD 2/8/2023:

-LIC500 Personnel Report

-LIC308 Designation of Administrative Responsibility

-LIC610E Emergency Disaster Plan ARF LIC610D

-An updated copy of Administrator certificate

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/01/2023 06:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by locking 2 side gates and 1 in the backyard which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/02/2023
Plan of Correction
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Staff removed lock during inspection. Deficiency cleared.

Civil penalty of $500 is being assessed.
Type A
Section Cited
CCR
87705(f)(1)(2)
87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee cleaning supplies and sharps, located in a unlocked kitchen cabinet. The licensee did not comply with the section cited above which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/02/2023
Plan of Correction
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Caregiver locked the kitchen cabinet, deficiency cleared during visit.
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) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/01/2023 06:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
87506(a) Resident Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative...
This requirement was not met as evidence by:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation licensee did not comply with the section cited above by not having residents’ R1,R2, R3, R4, R5 and R6 records not completed which poses a potential health and safety risk to residents in care.
POC Due Date: 02/08/2023
Plan of Correction
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Licensee agreed to submit a written doctors order for bedrails for R1, R2, R3 R4, R5 and R6 to CCLD no later than the POC date.
Type B
Section Cited
CCR
87608(a)(3)
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide ... Postural supports may be... (3) A written order from a physician indicating... postural support shall be maintained... require other additional ...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation licensee did not comply with the section cited above by not having a written order for bed rails for R1, R2, R3, R4, R5 and R6 from a physician which poses a potential health and safety risk to residents in care.
POC Due Date: 02/08/2023
Plan of Correction
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Licensee agreed to submit a written doctors order for bedrails for R1, R2, R3, R4, R5 and R6 to CCLD no later than the POC date.
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) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 02/01/2023 06:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086(a)(c)
Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change . . . (c) Prior to construction or alterations, state or local law requires that all facilities secure a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by alterations to garage, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/15/2023
Plan of Correction
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Administrator agreed to provide a permit for the alterations completed in the garage to CCLD no later than the POC date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
LIC809 (FAS) - (06/04)
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