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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607231
Report Date: 09/01/2021
Date Signed: 09/01/2021 02:56:14 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:A HELPING HAND SOUTH BAYFACILITY NUMBER:
197607231
ADMINISTRATOR:SUSAN COOPERFACILITY TYPE:
740
ADDRESS:4848 134TH PL.TELEPHONE:
(310) 973-1315
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY:6CENSUS: 6DATE:
09/01/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Sue CooperTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analysts (LPA) Jey Cardenas conducted case management visit to the above facility; Upon arrival at the facility LPA conducted a risk assessment over the telephone with administrator, Sue Cooper; based on the assessment, the facility is clear of Covid-19 infection. LPA met with Miss Cooper, who assisted with the visit, the purpose of the visit was explained.

LPA observed deficiency during the complaint investigation visits which were conducted on 7/26/21 and 8/24/21; The following was discussed with the Administrator and staff; Per doctors’ orders R1 Risperidone should be given .125ML by mouth two times a day, may give another .125ML as needed for agitation at night. Per doctors’ orders R2 Risperidone should be given ½ML in the morning and 1 ML at bedtime. During interviews with staff#2 (S2) indicates that R1 is given a few drops of Risperidone; one time at night and R2 is given more Risperidone than R1, one time in the morning and one at night. Staff#3 (S3) indicates that R1 is given tiny amount one time a day after dinner and R2 is given one time after dinner. Administrator indicates that R1 is given .25ML Risperidone at night and R2 is given Risperidone one time at night. LPA found that Risperidone medication isn't being administered to resident according to doctors’ orders.

In addition, On 7/26/21 LPA also observed Medication Administration Record (MAR) for all six (6) residents were not being completed/ initialed by staff after medication was administered. S1 indicates that staff know when medication is administered to residents because they prep it in residents pill container for the day.

The following deficiency is cited under title 22 regulations, Exit interview conducted. Report to be provided via email with Appeal rights.


SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: A HELPING HAND SOUTH BAY
FACILITY NUMBER: 197607231
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/10/2021
Section Cited

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Incidental Medical and Dental Care. When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement not met as evidenced by: During
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complaint investigation visits LPA interviewed staff, LPA inquired about medication dosages and times, LPA reviewed doctors orders and medication is not being administered per doctors orders.
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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: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2021
LIC809 (FAS) - (06/04)
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