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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880590
Report Date: 03/06/2024
Date Signed: 03/06/2024 03:34:26 PM

Document Has Been Signed on 03/06/2024 03:34 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HANDS THAT HELP LLC, THEFACILITY NUMBER:
331880590
ADMINISTRATOR:DAVIS, SHAWNIQUAFACILITY TYPE:
735
ADDRESS:4378 CHARLTON AVETELEPHONE:
(619) 723-9899
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY: 6CENSUS: 2DATE:
03/06/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:32 PM
MET WITH:Shawniqua Davis - LicenseeTIME COMPLETED:
03:43 PM
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced Case Management Incident visit. LPA was greeted and granted entry by Licensee Shawquina Davis who was informed of the purpose of the visit.

The visit is in response to the death of Client One (C1), whom passed away on 03/05/2024. LPA conducted a tour of the facility, interviews, and collected documents. LPA reviewed C1's file and obtained copies of the following: ID/emergency Information, admission agreement, Physician's reports, Individual Program Plan, progress notes, and medication records (MARs) for the last 30 days.

During today's visit no deficiencies were cited in regard to this incident.

An exit interview was conducted, and a copy of this report was provided to Licensee Davis along with a copy of the LIC 811.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2024
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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