Community Care Licensing

FACILITY NAME:	HAND IN HAND CARE HOME		FACILITY NUMBER:	107209222
ADMINISTRATOR:	PETIL, DIVINA		FACILITY TYPE:	740
ADDRESS:	4361 W. FREMONT AVE		TELEPHONE:	(559) 389-0315
CITY:	FRESNO	STATE: CA	ZIP CODE:	93722
CAPACITY:	6	CENSUS: 4	DATE:	03/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:57 AM
MET WITH:			TIME COMPLETED:	06:00 PM

SUPERVISOR'S NAME: Sergiy Pidgirny TELEPHONE: (559) 246-0610 LICENSING EVALUATOR NAME: Katie Brown TELEPHONE: (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

Document Has Been Signed on 03/21/2023 05:28 PM - It Cannot Be Edited

FACILITY NAME: HAND IN HAND CARE HOME	FACILITY NUMBER: 107209222
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/21/2023

Type B

Section Cited

CCR

87412(a)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on Interview and record review, the licensee did not comply with the section cited above in 2 of 2 staff personnel records, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/04/2023
	Plan of Correction
1 2 3 4	AD has agreed to conduct an audit of all resident files and employee files. A checklist for resident and employee files will be completed for each resident. Missing items will be completed and added. A complete checklist will be provided to CCLD by the due date. LIC311F provided by LPA.

Type B

Section Cited

CCR

87465(d)(3)

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 4 resident MAR record reviews, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/04/2023
	Plan of Correction
1 2 3 4	AD has agreed to implement the use of a PRN log which includes all required documentation. A log will be placed in each resident file and used as required. A copy of the log will be provided to CCLD by the due date

SUPERVISOR'S NAME: Sergiy Pidgirny TELEPHONE: (559) 246-0610 LICENSING EVALUATOR NAME: Katie Brown TELEPHONE: (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

Document Has Been Signed on 03/21/2023 05:28 PM - It Cannot Be Edited

FACILITY NAME: HAND IN HAND CARE HOME	FACILITY NUMBER: 107209222
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/21/2023

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/04/2023
	Plan of Correction
1 2 3 4	AD has agreed to create a log and implement quarterly emergency drills which will contain the required information. Per AD, documentation of each drill will be maintained in a binder at the facility. A copy of the drill form will be provided to CCLD by the due date.

Type B

Section Cited

CCR

87705(c)(3)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: 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 for 2 of 2 employees, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/04/2023
	Plan of Correction
1 2 3 4	AD has agreed to conduct an audit of staff training. Required Dementia and identified missing training will be provided and documented. A completed training log for S1 and S2 will be provided to CCLD which documents all requirements by the due date.

SUPERVISOR'S NAME: Sergiy Pidgirny TELEPHONE: (559) 246-0610 LICENSING EVALUATOR NAME: Katie Brown TELEPHONE: (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