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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201041
Report Date: 04/09/2024
Date Signed: 04/09/2024 04:26:59 PM


Document Has Been Signed on 04/09/2024 04:26 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:CARING HANDSFACILITY NUMBER:
019201041
ADMINISTRATOR:MORALES, MERCEDESFACILITY TYPE:
740
ADDRESS:3536 MURPHY STREETTELEPHONE:
(925) 330-5129
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 2DATE:
04/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Wilma Nacis, CaregiverTIME COMPLETED:
04:40 PM
NARRATIVE
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On 4/9/2024 at 9:50AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Caregiver, Wilma Nacis and explained the purpose of the visit. LPA spoke with Administrator, Mercedes Morales over the phone and stated that caregiver can sign the licensing reports.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full and last serviced on 9/11/2023. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 110.8 degrees F in the hallway bathroom. LPA observed grab bars and non-skid mat in the bathrooms. There were adequate lights in each room. First Aid kit is complete. Last disaster drill was conducted on 3/14/2024.

LPA reviewed 2 resident and 3 staff files starting at 10:45AM. LPA reviewed residents' medications starting at 2:30PM. LPA interviewed 2 residents and 2 staff at 3:00PM.

At 11:50AM, LPA observed R1 does not have physician's report and TB test result on file during record review.

At 2:50PM, LPA observed doctor's order (dated 11/2/2023) for R1's vitamin D3 was for 50mcg and Acetaminophen was for 325mg. However, facility has bottles of vitamin D3 125mcg and Acetaminophen 500mg. Facility does not have Lidocaine 4% top cream available for R1 with a doctor's order.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
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 4


Document Has Been Signed on 04/09/2024 04:26 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: CARING HANDS
FACILITY NUMBER: 019201041

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having physician's report for R1 which poses a potential health and safety risk to persons in care.
POC Due Date: 04/30/2024
Plan of Correction
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Administrator has agreed to obtain R1's physician's report and TB test results. Administrator will submit a copy to CCLD by 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 04/09/2024 04:26 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: CARING HANDS
FACILITY NUMBER: 019201041

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can 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:
(2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not following doctor's order for R1's medications which poses an immediate health and safety risk to persons in care.
POC Due Date: 04/10/2024
Plan of Correction
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Administrator has agreed to obtain medications/supplements as stated in doctor's order for R1 or obtain new doctor's orders for Vitamin D3, Acetaminophen, and Lidocaine. Administrator will submit picture proof to CCLD by 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4