374603525-9-29-2023-08-AS-DNGN-CW633J-20230929175336

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603525
Report Date: 09/29/2023
Date Signed: 09/29/2023 05:54:40 PM

Document Has Been Signed on 09/29/2023 05:54 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 HOME		FACILITY NUMBER:	374603525
ADMINISTRATOR:	RUTH LOPEZ		FACILITY TYPE:	735
ADDRESS:	211 E. OXFORD STREET		TELEPHONE:	(619) 737-9799
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91911
CAPACITY: 4		CENSUS: 4	DATE:	09/29/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	House Manager Sara Verastegui and Administrator Ruth Lopez		TIME COMPLETED:	06:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with House Manager Sarah Verastegui. LPA also met with Administrator Ruth Lopez, who arrived later during the visit.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 09/28/2023). According to the LIC624: during the evening of 09/26/2023, Client #1 (C1) left the facility without informing staff. By the morning of 09/27/2023, C1 still had not returned to the facility and thus did not receive some of their morning prescribed medications. [See LIC 811 Confidential Names List for a description of C1.]

During today’s visit, LPA performed a facility tour and welfare check on clients in care. LPA also reviewed pertinent records and interview relevant staff.

According to C1’s latest LIC602 Physician’s Report (dated 05/08/2023), their doctor determined that C1 was able to safely leave the facility unassisted.

Interviews, corroborated by records, showed: After C1 departed, facility staff used electronic means to correspond with C1 to receive updates on their whereabouts. C1 went to a family member’s house around 3:00 AM on 09/27/2023, and then returned to the facility later that same day and received their evening prescribed medications as scheduled. C1 was unharmed/uninjured from the incident. C1 also did not have any adverse health symptoms from missing their morning medications on 09/27/2023. Licensee’s staff also met reporting requirements.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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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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: 09/29/2023

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[CONTINUED FROM LIC 809]

During a review of records, LPA observed that Licensee did not possess a written Absentee Notification Plan for C1, as was required. Manager interview confirmed that neither C1 nor the other clients in care (C2 through C4) had an Absentee Notification Plan as part of their respective written records of care.

One (1) deficiency was cited per California Health and Safety Code (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. LPA also issued Technical Assistance (TA) regarding use of auditory staff alert devices on exterior doors (see the LIC 9102-TA).

An exit interview was conducted with Verastegui, to whom a copy of this report, the LIC809-D, the LIC9102-TA, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/29/2023 05:54 PM - It Cannot Be Edited

Created By: Dang Nguyen On 09/29/2023 at 05:27 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: 09/29/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/29/2023 Section Cited HSC 1507.15	1 2 3 4 5 6 7	1507.15 Absentee notification plan for missing residents or participants: “Every community care facility that provides adult residential care… shall…develop and comply with an absentee notification plan for each resident... The plan shall be part of the written Needs and Services Plan [and] shall include…a requirement that an administrator of the facility, or his or her designee, inform the resident’s...authorized representative when that resident...is missing from the facility and the circumstances…in which [they]…shall notify local law enforcement…”	1 2 3 4 5 6 7	Licensee agreed to write an Absentee Notification Plan/policy meeting the requirements of CA H&S Code 1507.15, and to train all its direct care staff on it. Licensee also agreed to place a copy of said Absentee Notification Plan in the care file for every current and future client in care, right next to (i.e., as an addendum to) that client’s Needs and Services Plan. Licensee agreed to E-mail the Plan and the training sign-in sheet to LPA, by the POC due date.
	8 9 10 11 12 13 14	This requirement was not met, as evidenced by: Based on records and interviews, the licensee did not develop/possess an absentee notification plan for 4 of 4 clients (C1 through C4), which posed a potential safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 09/29/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

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