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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603525
Report Date: 12/24/2024
Date Signed: 12/24/2024 04:21:34 PM

Document Has Been Signed on 12/24/2024 04:21 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:HEALING HANDS ADULT CARE HOMEFACILITY NUMBER:
374603525
ADMINISTRATOR/
DIRECTOR:		RUTH LOPEZFACILITY TYPE:
735
ADDRESS:211 E. OXFORD STREETTELEPHONE:
(619) 737-9799
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 4CENSUS: 4DATE:
12/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:House Manager Sara VerasteguiTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to conduct a Required Annual Inspection. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with House Manager Sara Verastegui.

According to the facility’s license, the facility has a maximum capacity of four (4) clients, of whom all must be ambulatory. Per combination of LIC602 Physician’s Reports, staff interviews, and LPA observation: During today’s inspection, there were a total of four (4) clients in care [Client #1 (C1), Client #2 (C2), Client #3 (C3), and Client #4 (C4)], of whom all were ambulatory. [See LIC811 Confidential Names List pages of a description of select person identifiers used in this report.] The facility’s license does not include endorsements for delayed-egress doors or secured perimeter, and neither of these were present.

During today’s visit, LPA performed a welfare check and interviewed multiple clients and multiple staff. LPA reviewed the care records for all clients and personnel records for all staff. LPA, accompanied by staff, also toured the interior and exterior of the facility, and inspected all common areas and client bedrooms.

The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Hot water temperature at taps accessible to clients were compliant in temperature: Kitchen Sink was 108.9 F, Bathroom #1 Sink was 116.8 F, Bathroom #2 Sink was 110.7 F, and Bathroom #3 Sink was 115.3 F. The facility’s ambient internal temperature was complaint at 74 F. Extra supplies of linens, toiletries, and Personal Protective Equipment (PPE) were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Appliances to preserve perishable food were also compliant in temperature. There were at least (2) days of perishable food and at least seven (7) days non-perishable food present, all safely stored.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 12/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/24/2024
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 4
Document Has Been Signed on 12/24/2024 04:21 PM - It Cannot Be Edited


Created By: Dang Nguyen On 12/24/2024 at 03:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HEALING HANDS ADULT CARE HOME
FACILITY NUMBER: 374603525

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(b)(2)(C)
Infection Control Requirements
(b) In addition to subsection (a), when one or more clients in the facility are diagnosed with a contagious disease, the following shall apply:  (2) All staff and volunteers providing direct care to a client who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth.  PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection.  (C) The licensee shall ensure all staff and volunteers are trained in the proper use of all required PPE prior to being around clients and annually thereafter. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on records review and interviews, Licensee did not ensure that 9 of 9 facility staff (S1 through Staff #9) were trained in the proper use of all required PPE annually. This posed a potential health risk to 4 of 4 clients (C1 through C4) in care.
POC Due Date: 01/24/2025
Plan of Correction
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Licensee agreed to conduct PPE training for all current staff. The training will include hands-on practice and will cover: a) how perform an N-95 seal check, b) how to correctly don and doff surgical masks, N-95 respirators, face shields, gowns, and gloves, and c) how to set up and manage an isolation bedroom. Licensee agreed to E-mail the training sign-in sheet to LPA, by the POC due date. Going forward, Licensee agreed to repreat this training at least annually.
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview, Licensee did not possess a completed and signed health screening for 3 of 9 staff (S1, S2, and S3). This posed a potential health and safety risk to 6 of 6 clients (C1 through C4) in care.
POC Due Date: 01/24/2025
Plan of Correction
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Licensee agreed to have S1, S2, and S3 each go to a doctor in order to each complete an LIC503 Health Screening. Licensee agreed to E-mail the completed and signed LIC503 forms for S1, S2, and S3 to LPA, by the POC due date. Licensee agreed to add the completed LIC503 forms to their personnel records.
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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 12/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/24/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/24/2024 04:21 PM - It Cannot Be Edited


Created By: Dang Nguyen On 12/24/2024 at 03:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HEALING HANDS ADULT CARE HOME
FACILITY NUMBER: 374603525

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(b)
Other Provisions
(b) If a facility employs staff, the facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and interviews, Licensee did not ensure that 9 of 9 facility staff (Staff #1 through Staff #9) were trained on the facility's written emergency and disaster plan at least annually. This posed a potential safety risk to 4 of 4 clients (Client #1 through Client #4) in care.
POC Due Date: 01/24/2025
Plan of Correction
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Licensee agreed to train all current staff on the facility's LIC610D Emergency and Disaster Plan. Licensee agreed to E-mail the training sign-in sheet to LPA, by the POC due date. Going forward, Licensee agreed to repreat this training at least annually.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 12/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/24/2024


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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: HEALING HANDS ADULT CARE HOME
FACILITY NUMBER: 374603525
VISIT DATE: 12/24/2024
NARRATIVE
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[CONTINUED FROM LIC 809]

Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas. Per the Licensee, no firearms or ammunition were kept at the facility. No pools or bodies of water were observed on the premises. The facility’s fireplace was screened, as required. Smoke detectors, carbon monoxide detector, emergency lighting, night lights, and facility telephone were all working. The facility’s fire extinguishers were serviced within the last twelve (12) months. Licensee presented proof of current business liability insurance and surety bond.

During a review of personnel and training records, LPA observed, and manager interview confirmed: Licensee did not possess an LIC503 Health Screening (or equivalent pre-employment physical completed by a doctor) for 3 of 9 facility staff [Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3)]. (All staff did have proof of negative tuberculosis screening, however.) Licensee did not have proof that direct care staff had been trained on PPE within the last year, as required. Licensee did not have proof that direct care staff had been trained on the facility’s written LIC610D Emergency and Disaster Plan (and their responsibilities under it) within the last year, as required.

Two (2) deficiencies were cited per California Code of Regulations, Title 22, and one (1) deficiency was cited per California Health and Safety Code (refer to the LIC 809-D pages). Plans of Correction were jointly developed with the Licensee. LPA also issued Technical Assistance (TA) regarding obtaining an updated LIC602 Physician’s Report for C1 and conducting refreshed training on Mandated Reporter requirements for staff (refer to the LIC9102-TA pages).

An exit interview was conducted with Sara Verastegui. A copy of this report, the LIC 809-D pages, the LIC9102-TA pages, the LIC811 Confidential Names List page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Licensee during today's visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2024
LIC809 (FAS) - (06/04)
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