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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701191
Report Date: 09/21/2023
Date Signed: 09/21/2023 05:15:30 PM


Document Has Been Signed on 09/21/2023 05:15 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:CA CARING HANDSFACILITY NUMBER:
342701191
ADMINISTRATOR:KHAN, SHAHBAZFACILITY TYPE:
740
ADDRESS:8797 TWINBERRY WAYTELEPHONE:
(916) 667-3248
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
09/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Homaira Momen TIME COMPLETED:
05:30 PM
NARRATIVE
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On 9/21/23 at approximately 2:00pm Licensing Program Analyst (LPA) Jennifer Fain arrived at this facility unannounced to conduct a continuation of the annual inspection visit. LPA met with Homaira Momen and explained the purpose of the visit.

LPA spoke with administrator by phone regarding items missing from resident and staff files including, but not limited to:

Staff 1 (S1) was not associated with the facility, but was fingerprint cleared. Administrator will associate S1 by end of day.

Resident file review showed Resident 6 (R6) has 2 restricted health conditions. Facility does not have an exception nor is there documentation for Home Health Services. Licensee states hospital discharged Resident with Home Health services but specified agency declined patient. Case manager, PCP and Licensee are working to find another provider.

The facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted with Homaira Momen and a copy of the LIC 809 report, LIC 809-D pages, and Appeals rights were provided.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer FainTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
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


Document Has Been Signed on 09/21/2023 05:15 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: CA CARING HANDS
FACILITY NUMBER: 342701191

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/22/2023
Section Cited
CCR
87613

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General Requirements for Restricted Health Conditions (a) Prior to admission of a resident with a restricted health condition, the licensee shall:(2) Ensure that facility staff...complete training provided by a licensed professional sufficient to meet those needs. This requirement is not met as evidenced by:
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Licensee will submit documentation to receive exceptions for the restricted health conditions by end of day on 9/22/23.
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Based on record review, the licensee did not acquire an exception for catheter and insulin care, restricted conditions, which poses an immediate Health, Safety and Personal Rights risk to persons in care.
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Type B
09/29/2023
Section Cited
CCR87405

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Administrator - Qualifications and Duties
(d) (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by:
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Licensee will send a plan of correction by 9/29/23.
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Based on record review, staff and resident files were missing required components which poses a potential Health, Safety and Personal Rights risk to persons 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer FainTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2