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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701191
Report Date: 10/03/2023
Date Signed: 10/03/2023 06:07:05 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/03/2023 06:07 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:
10/03/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Janice RiveraTIME COMPLETED:
06:30 PM
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On 10/3/23 at approximately 2:40pm Licensing Program Analyst (LPA) Jennifer Fain arrived at this facility unannounced to continue an annual inspection visit. LPA met with Homaira Momen and explained the purpose of the visit.

During this inspection 4 of 6 resident files and 6 of 6 staffing files were reviewed for regulatory compliance.
Staff files contained required contents including staff training requirements. 1 of 6 Staff files was missing a signed Criminal Record Statement. All staff noted on LIC 500 contained criminal background clearances.
Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required.

LPA observed the 602 for Resident 2 (R2) stated bedridden status. The facility Plan of Operations does not address bedridden care. LPA observed the facility is licensed for 6 non-ambulatory with 6 hospice waivers, but does not have bedridden status. Technical Assistance (TA) was provided regarding fire clearance and waivers. LPA observed R2 at the dinner table. Licensee will confirm bedridden status and apply for clearance and waivers as needed.

LPA observed the 602 for Resident 5 (R5) states R5 has dementia and is “at risk if allowed direct access to personal grooming and hygiene products.” LPA observed hygiene products in R5’s room and shared bathroom. TA was provided and products were removed.

LPA observed cameras in 2 of 6 resident rooms and two in the common areas of the residence. The cameras in the resident rooms were removed immediately. LPA provided (TA) regarding cameras in residence. Cameras must be addressed in the Plan of Op and admissions agreement. Licensee states Plan of Op will be updated and an addendum to the Admissions agreement will be signed by each resident or responsible party.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer FainTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
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 3


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
VISIT DATE: 10/03/2023
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Water temperature in common bathroom reads 117.7*F which is within the regulated temperature range of 105*F to 120*. Temperature on the heating and air unit read 69*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were tested and in working order. The fire extinguisher was found to be in compliance. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. The first aid kit was observed to have adequate supplies and was accessible to staff. Facility does not contain any bodies of water. Facility’s liability insurance is current and up to date per regulatory requirements. LPA observed personal rights, resident council and complaint information posted. Facility has appropriate internet access available for resident use.

Licensee was offered and accepted participation in the TSP Program.

The facility is not in compliance with the California Code of Regulations, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted with Homaira Momenand and a copy of the LIC 809 reports, 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: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/03/2023 06:07 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: 10/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/03/2023
Section Cited
CCR
87468.2

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(a)… residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations... This requirement is not met as evidenced by:
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The cameras were removed from the residents’ rooms. No further correction is required.
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Based on observation and interview the licensee did not provide privacy to 2 of 6 residents due to cameras in their private rooms, which poses a potential Health, Safety and/or 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: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
LIC809 (FAS) - (06/04)
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