374604222-12-12-2023-08-AS-DSEA-CYG9FY-20231212222039

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604222
Report Date: 12/12/2023
Date Signed: 12/12/2023 10:21:08 PM

Document Has Been Signed on 12/12/2023 10:21 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:	HANDS THAT HELP, LLC - MANZANA, THE		FACILITY NUMBER:	374604222
ADMINISTRATOR:	BROOKINS, PAMELA		FACILITY TYPE:	735
ADDRESS:	1395 MANZANA WAY		TELEPHONE:	(619) 723-9899
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92139
CAPACITY: 4		CENSUS: 4	DATE:	12/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Shawniqua Davis, Licensee		TIME COMPLETED:	07:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced required annual inspection. LPA identified herself and was granted entry into the facility. Licensee, Shawniqua Davis, to whom LPA disclosed the purpose of the visit, arrived a short time later. According to the facility’s license, the facility is licensed for four (4) clients, all of whom must be ambulatory. During today’s inspection, there were four (4) clients in care, three (3) of whom were present during the visit. The facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by licensee, toured the interior and exterior of the facility. Pathways were free of obstruction and slip hazards. Doors, windows and screens were present and sinks and toilets were in working order. While touring the home, LPA observed that the bedroom door to one client bedroom had been removed from the hinges and propped against the bedroom wall. Hygiene supplies and Personal Protective Equipment were present. The facility had sufficient space and equipment to facilitate visitation, meetings, and client activities. The facility’s internal temperature was 68 degrees F. Hot water temperature in bathroom sinks in bathrooms that are accessible to clients initially measured at 143 and 148 degrees F. The hot water heater was adjusted during the visit and high water temperature signs were posted in each bathroom. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. A fireplace with appropriate screening was observed in the living area of the home. No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, and facility telephone were all working. Fire extinguishers were serviced within the last 12 months. First aid kit was complete and readily accessible.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

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 9

Document Has Been Signed on 12/12/2023 10:21 PM - It Cannot Be Edited

Created By: Dawn Segura On 12/12/2023 at 05:31 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: HANDS THAT HELP, LLC - MANZANA, THE	FACILITY NUMBER: 374604222
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80019(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, record review, and interview, the licensee did not comply with the section cited above in 1 of 1 staff present, which posed an immediate safety risk to persons in care.
	POC Due Date: 12/13/2023
	Plan of Correction
1 2 3 4	S1 immediately left the home and returned only to provide licensee with proof of live scan application. A copy of the live scan application was provided to LPA during the visit. Licensee confirmed that S1 will not return to the home until proof of criminal record clearance has been received.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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:

Dawn Segura

LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC809 (FAS) - (06/04)

Page: 2 of 9

Document Has Been Signed on 12/12/2023 10:21 PM - It Cannot Be Edited

Created By: Dawn Segura On 12/12/2023 at 05:31 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: HANDS THAT HELP, LLC - MANZANA, THE	FACILITY NUMBER: 374604222
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in 1 of 3 bedrooms, which poses a potential personal rights risk to persons in care.
	POC Due Date: 12/15/2023
	Plan of Correction
1 2 3 4	Licensee offered to ensure that the bedroom door will be properly reinstalled and proof of correction provided to Community Care Licensing by the POC due date of 12/15/2023.

Type B

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in 2 of 2 client bathrooms, which poses a potential safety risk to persons in care.
	POC Due Date: 01/09/2024
	Plan of Correction
1 2 3 4	Hot water heater was adjusted during the visit. Licensee offered to ensure that hot water temperature in each bathroom is measured each day until there are five consecutive days of the hot water temperature remaining within the required range. Hot water log will be provided to Community Care Licensing by the POC due date of 1/9/2024.

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:

Dawn Segura

LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC809 (FAS) - (06/04)

Page: 3 of 9

Document Has Been Signed on 12/12/2023 10:21 PM - It Cannot Be Edited

Created By: Dawn Segura On 12/12/2023 at 05:31 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: HANDS THAT HELP, LLC - MANZANA, THE	FACILITY NUMBER: 374604222
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85068.2(b)(1)(C)

Needs and Services Plan

(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's record review, the licensee did not comply with the section cited above in 1 of 4 clients in care, which poses potential health and safety risks to persons in care.
	POC Due Date: 01/09/2024
	Plan of Correction
1 2 3 4	Licensee offered to schedule an appointment to have a medical assessment and TB test completed for C2. Licensee offered to provide a copy of the medical assessment to Community Care Licensing by the POC due date of 1/9/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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:

Dawn Segura

LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC809 (FAS) - (06/04)

Page: 4 of 9

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: HANDS THAT HELP, LLC - MANZANA, THE	FACILITY NUMBER: 374604222
	VISIT DATE: 12/12/2023

NARRATIVE

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LPA interviewed staff and clients. LPA also reviewed staff and client records/files. Client 2’s (C2’s) file did not contain a Physician’s Report or proof of negative TB test result. Staff files contained proof of current first aid and negative TB test results. Confidential records were stored in locked areas.

Upon LPA’s arrival, it was discovered that the staff (S1) who was present and working in the facility did not have criminal background clearance. A civil penalty of $500 is being assessed and noted on an LIC421BG.

A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Shawniqua Davis, to whom a copy of this report, the LIC 809-D, the LIC421BG, LIC 9102TVs, LIC 9102TA, the LIC 811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the end of the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dawn Segura
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC809 (FAS) - (06/04)

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