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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209222
Report Date: 03/21/2023
Date Signed: 03/22/2023 04:22:29 PM


Document Has Been Signed on 03/22/2023 04:22 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:HAND IN HAND CARE HOMEFACILITY NUMBER:
107209222
ADMINISTRATOR:PETIL, DIVINAFACILITY TYPE:
740
ADDRESS:4361 W. FREMONT AVETELEPHONE:
(559) 389-0315
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:6CENSUS: 4DATE:
03/21/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:22 PM
MET WITH:Ronald SandoneTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown conducted a Case Management - Deficiencies in conjunction with the Annual Inspection. LPA Met with Licensee Ronald Sandone.

During the visit, LPA observed the following:
1. Medication cabinet was not locked
2. Medication in cup was left with a resident


A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D.



An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with Ronald Sandone, whose signature on this form confirms receipt of these documents.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 03/22/2023 04:22 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, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: HAND IN HAND CARE HOME
FACILITY NUMBER: 107209222

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/22/2023
Section Cited

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87411 Personnel Requirements – General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following… (4) Knowledge required to safely assist with prescribed medications which are self-administered.
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AD has agreed to provide medication in-service to S1. A written statement will be provided to CCLD by the due date which includes the materiels and topics reviewed, including regulation review. The statement will be signed by S1 and Licensee, submitted to CCLD by 5pm 3/22/22.
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This requirement was not met as evidenced by:
Licensee did not ensure that S1 had appropriate job training for assistance with resident medication. LPA observed the medication closet left unlocked as well as a cup with medications left with R2. S1 did not observe R2 taking medications. This poses an immediate health and safety risk to residents in care.
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Additionally, statement will include long term plan to ensure medication loset is locked at all times.

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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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2