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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202309
Report Date: 11/28/2023
Date Signed: 11/28/2023 01:52:17 PM

Document Has Been Signed on 11/28/2023 01:52 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
Lookup Error,
, CA
FACILITY NAME:HELPING HANDS RESIDENTIAL CARE HOME 2FACILITY NUMBER:
435202309
ADMINISTRATOR:JANESSA FLORESFACILITY TYPE:
735
ADDRESS:349 SPRING VALLEY LN.TELEPHONE:
(408) 956-8596
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY: 4CENSUS: 4DATE:
11/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Janessa Flores and Licensee Rowena CalingTIME COMPLETED:
02:00 PM
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On 11/28/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit.
introduce self, stated the purpose of the visit and met with Director Support Professional (DSP) Ofelia Diaz. Administrator (A1) Janessa Flores was called and arrived shortly. LPA toured facility with A1 and DSP. Licensee Rowena Caling arrived later during inspection. Three clients were present during inspection.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. An adequate supply of perishable and non-perishable food was observed. The temperature is maintained for refrigerator at -10 degrees F and freezer at 40 degrees F. At 11:15 AM, medications were observed unlocked in kitchen closet. MARs were reviewed.

Fire extinguisher was observed with a purchased date of: 2/11/23. Fire drill last completed:11/10/23.

All bedrooms were observed to have the required furnishings and with adequate lightening. The bathrooms were properly equipped and operating. Hot water temperature was tested at 115.7 in bathroom 1, 115.1 degrees in the bathroom 2, and 109.5 in bathroom 3. Cleaning supplies and chemicals stored and locked in garage cabinet.

Outside of facility toured and observed to be free of debris. Outdoor seatings observed available for clients. Side gate observed self-closing.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2023
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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Document Has Been Signed on 11/28/2023 01:52 PM - It Cannot Be Edited


Created By: Mai Yang On 11/28/2023 at 01:13 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
,
, CA

FACILITY NAME: HELPING HANDS RESIDENTIAL CARE HOME 2
FACILITY NUMBER: 435202309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPA and Administrator observed at approximately 11:15 AM, medication closet unlocked and accessible to client while three clients were present during inspection. Administrator stated medication closet door was unlock for 1 day due closet door needs a new battery which poses an immediate health, safety or personal rights risk to person in care.

POC Due Date: 11/29/2023
Plan of Correction
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Staff immediately removed all medications into locked room. Licensee replaced batteries for locked medication door during inspection. POC cleared during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:See Moua
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023


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
Lookup Error,
, CA
FACILITY NAME: HELPING HANDS RESIDENTIAL CARE HOME 2
FACILITY NUMBER: 435202309
VISIT DATE: 11/28/2023
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All clients’ files were reviewed to have all the required documents. Staff files were also reviewed. Staff files were observed to have all required documents, fingerprinted clear and associated to the facility. Carbon monoxide and smoke detectors were tested and observed to be operational.

A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. A copy of this report and appeal rights was provided to Administrator, whose signature on this form confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
LIC809 (FAS) - (06/04)
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