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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700434
Report Date: 11/16/2023
Date Signed: 11/16/2023 12:52:54 PM


Document Has Been Signed on 11/16/2023 12:52 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:CARING HANDS A RESIDENTIAL FACILITYFACILITY NUMBER:
502700434
ADMINISTRATOR:ACEDO, MARIAFACILITY TYPE:
740
ADDRESS:524 E UNION AVETELEPHONE:
(209) 497-8400
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:6CENSUS: 4DATE:
11/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Marlene AvenaTIME COMPLETED:
01:30 PM
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Licensing Program Analysts (LPA) Kesha Lewis arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA was met by staff. LPA explained the purpose of the visit to staff. Administrator joined about one (1) hour later.

LPA and staff inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 4. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. Chemicals and medications noted to be locked to residents in care. LPA also conducted the care tool.

Hot water temperature was measured at 108 F degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. All necessary documents were in place. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils.

The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: CARING HANDS A RESIDENTIAL FACILITY
FACILITY NUMBER: 502700434
VISIT DATE: 11/16/2023
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LPA observed the facility to have adequate food supply of 7 days non-perishables and 2 days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings.

LPA observed, fire extinguishers inspected on 06/02/2023 and current, smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution.

LPA reviewed two (2) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required.



LPA reviewed two (2) resident facility files, COVID-19 Plan, and survey binder. All necessary documents were in place.

Exit interview held with staff and copies of reports left at conclusion of visit.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2