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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881462
Report Date: 09/04/2024
Date Signed: 09/04/2024 10:09:31 AM

Document Has Been Signed on 09/04/2024 10:09 AM - 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:A HELPING HAND ARFFACILITY NUMBER:
331881462
ADMINISTRATOR/
DIRECTOR:		SANSBERRY, MIKEEDAFACILITY TYPE:
735
ADDRESS:772 WINDING TRAILTELEPHONE:
(424) 347-0476
CITY:SAN JACINTOSTATE: CAZIP CODE:
92582
CAPACITY: 4CENSUS: 2DATE:
09/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:48 AM
MET WITH:ADMINISTRATOR, MIKEEDA SANSBERRYTIME VISIT/
INSPECTION COMPLETED:
10:12 AM
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On September 04, 2024, Licensing Program Analyst (LPA), Venus Mixson, made an unannounced visit to the facility for the purpose of conducting the Required Annual inspection, and met with Jessica Garrison, Direct Support Personal #2(DSP2), introduced herself and stated the purpose for the visit. The Facility File review was conducted in the office and additional forms were requested and reviewed on site.

Infection Control: LPA Mixson observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found all required infection control measures. Additionally, staff took LPA's temp and logged it in.

PHYSICAL PLANT: Facility is licensed for four Adult Residents and is operating at two which is within the conditions and limitations of the license. Outdoor and indoor passageways are kept free of obstruction. No pool or body of water was observed on the property. According to staff, there are no known weapons kept in the home. Disinfectants, cleaning solutions, and poisons were inaccessible to residents in care. Temperature was within in regulations for this time of day and the season. There was sufficient lighting throughout the facility and the Hot water tested within regulations at 112. degrees F. Fire extinguisher located in kitchen area has proper inspection tag. The smoke and carbon monoxide alarms were in the green and last inspected on August 01, 2024, By the State Fire Marshall. The interior and exterior areas of the home were observed to be clean and organized.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: A HELPING HAND ARF
FACILITY NUMBER: 331881462
VISIT DATE: 09/04/2024
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 Continued LIC809C.

FOOD SERVICE: There was a variety of food which appeared to be selected and stored in a safe and healthful manner. Food supply of nonperishable and perishable foods was sufficient. The kitchen was observed to be clean and neat and organized. LPA observed the required two-day supply of perishable and seven-day supply of non-perishable foods. Facility shops weekly or as needed.

Care & Supervision/Administration: Adequate staffs are present for the supervision of residents in care. Floor plans, telephone numbers and personal rights were found posted in the facility. The listed administrator possesses an administrator certificate that does not expire until 04/17/2025.

Record Review and Resident/Staff Files: LPA reviewed one staff file and reviewed the facility's staff schedule. The staff file reviewed had criminal clearance and updated training along with CPR/First Aid Certification. Two Resident files were reviewed and possessed all required paperwork, with current TB test.



MEDICATION: Medications were reviewed for two Residents in care. The medications reviewed were labeled and maintained in compliance with label instructions and State and Federal law. Medications were observed to be safe, locked, and inaccessible to Residents in care. Medications and medication documentation was observed to be well organized and monitored, Parkview Medical Plaza Pharmacy delivers to the facility.

Disaster preparedness: LPA Mixson reviewed the facility's emergency and disaster plan as well as disaster training binder. LPA observed the last fire drill to be conducted on August 02. 2024, it is posted and logged in the facility Emergency Disaster binder, met the department standards.

No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations at this time.


An exit interview was conducted where a copy of this report was discussed and given to DSP2, Jessica Garrison.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC809 (FAS) - (06/04)
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