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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701191
Report Date: 10/20/2023
Date Signed: 10/20/2023 01:06:11 PM


Document Has Been Signed on 10/20/2023 01:06 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



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: 5DATE:
10/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Shahbaz KhanTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to obtain additional information regarding the care and supervision of residents. LPA met with Shahbaz Khan and stated the purpose of the visit. LPA observed three resident files (R1-R3).

LPA interviewed Applied Hospice staff during this visit.

Administrator Shahbaz Khan contacted the Fire Dept to schedule a pre-inspection to ensure and determine which rooms are allowed to maintain bedridden residents as the facility is approved for 6 hospice residents.

LPA reviewed the meaning of exception, waiver, bedridden, total care, records, non-ambulatory, and the use of Technical Support Program (TSP).

Of the 3 files reviewed, LPA observed R1 is not using a catheter, R2 is utilizing hospice services and periodically using a condom catheter which Home Health is maintaining through visits 5x week along with using incontinence supplies. R3 is using a purewick catheter but is able to maintain the self-care with assistance. R4 who needed catheter care was relocated by the POA as there was no exception in place.

LPA inquired about the exception requests that was submitted to the Department. LPA deemed the exceptions are not needed at this time.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies cited.
Exit interview held, copy of report given
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023
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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