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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336427442
Report Date: 05/25/2021
Date Signed: 05/25/2021 04:10:42 PM

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:GOLDEN HANDS FAMILY HOME CARE LLCFACILITY NUMBER:
336427442
ADMINISTRATOR:BANARES, ROSITA DFACILITY TYPE:
740
ADDRESS:1022 SAW TOOTH LANETELEPHONE:
(951) 537-9850
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY:6CENSUS: 4DATE:
05/25/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Rosita BanaresTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jennifer Semin conducted this case management visit in conjunction with Complaint number 18-AS-20210521103511 LPA met with Rosita Banares

During the course of the complaint investigation on 5/25/2021. Ms. Banares stated she did not maintain a resident's file after they were discharged. Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.
This requirement was not met as evidence by LPA was unable to review resident file as it was not present. This poses a potential health and safety risk to residents in care. A deficiency will be cited.

An exit interview was conducted where this report and appeal rights were discussed and provided to Ms. Banares.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021
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 2
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: GOLDEN HANDS FAMILY HOME CARE LLC
FACILITY NUMBER: 336427442
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/01/2021
Section Cited

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87506(e) Resident Records
Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was not met as evidence by LPA was unable to review resident file as it was not present. This poses a potential health and safety risk to residents in care

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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: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2