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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200895
Report Date: 07/22/2024
Date Signed: 07/22/2024 04:45:17 PM

Document Has Been Signed on 07/22/2024 04:45 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SACRED HANDS LIVING IIIFACILITY NUMBER:
079200895
ADMINISTRATOR/
DIRECTOR:		PANESAR, RAJWANT KAURFACILITY TYPE:
740
ADDRESS:536 LAKE PARK CTTELEPHONE:
(209) 762-2910
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 0DATE:
07/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:03 PM
MET WITH:PANESAR, RAJWANT KAUR, ADMINISTRATORTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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On 07/22/2024 at 2:03PM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Administrator Rajwant Kaur Panesar, and explained the purpose of the visit. The facility’s fire clearance was approved for six (6) bedridden residents. The facility has no residents at this time.

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of five (5) bedrooms and two (2) bathrooms. four (4 bedrooms for residents, one (1) staff bedroom. All outdoor and indoor passageways are kept free of obstruction. LPA did not observe any bodies of water. A comfortable temperature is maintained at 82 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 109.6 degrees Fahrenheit. Clients’ bathrooms are equipped with grab bars and nonskid mats.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 07/22/2024. Emergency Disaster Plan was last posted on 06/302024. First aid kit was observed to be complete. No fire drill has been conducted; facility doesn't have any residents.

Continued LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SACRED HANDS LIVING III
FACILITY NUMBER: 079200895
VISIT DATE: 07/22/2024
NARRATIVE
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Continued from LIC809.
One (1) resident file was reviewed, although there are no residents at the facility at this time. NO staff files were available for review during visit.


The following deficiencies observed during visit.

At 3:20PM LPA observed Administrator didn't have an Administrator Certificate or proof of payment/processing
At 3:30PM during record review LPA observed One (1) out of the previous three(3) resident's files were available for review
At 3:45PM during record review LPA observed there were no staff files available for review

The following forms to be updated and submitted to CCLD by 07/29/2024:
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· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond
· LIC610D Emergency Disaster Plan
· LIC308 Designation of facility responsibility
·

Exit interview conducted and a copy of this report provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/22/2024 04:45 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 07/22/2024 at 04:21 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: SACRED HANDS LIVING III
FACILITY NUMBER: 079200895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87406(g)
87406 Administrator Certification Requirements
(g) Certificates issued under this section shall be renewed every two (2) years provided the certificate holder has complied with all renewal requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in not having Administrator Certificate which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2024
Plan of Correction
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2
3
4
Administrator agreed to send an email photo of Administrator Certificate and or proof of processing to CCLD by POC date.
Type B
Section Cited
CCR
87412(f)
87412 Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in having personnel records at the facility and available for Licensing to review which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2024
Plan of Correction
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2
3
4
Administrator agreed to review section 87412 and to complete all client files and submit a self-certification that to CCLD by POC date that files have been completed.
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:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/22/2024 04:45 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 07/22/2024 at 04:30 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: SACRED HANDS LIVING III
FACILITY NUMBER: 079200895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(d)
87506 Resident Records
(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in not having residents files available at the facility for licensing to review which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2024
Plan of Correction
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2
3
4
Administrator agreed to review section 87506 and to complete all residents files and submit a self-certification that to CCLD by POC date that files have been completed.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024


LIC809 (FAS) - (06/04)
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