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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701007
Report Date: 05/23/2023
Date Signed: 05/23/2023 12:46:46 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/23/2023 12:46 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:CARING HANDS A RESIDENTIAL FACILITYFACILITY NUMBER:
502701007
ADMINISTRATOR:ACEDO, MARIA CRISTINAFACILITY TYPE:
740
ADDRESS:2912 WESTPORT CIRCLETELEPHONE:
(209) 549-6945
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY:6CENSUS: 4DATE:
05/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:48 AM
MET WITH:M. AcedoTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an Annual Inspection Visit. LPA met with house manager and explained the purpose of the visit. Later joined by Administrator

LPA and house manager inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed two areas used as staff room which are not approved areas included on the fire clearance. LPA observed in R1's room a camera that is facing the bed. There is no wavier for the use of this camera. Hot water temperature was measured at 122.8 degrees Fahrenheit in resident bathroom sink, which is not within the required range of 105 to 120 degrees. Fire extinguishers inspected and smoke detectors are operational. LPA observed carbon monoxide detectors in the facility. Fire drill was conducted on 3/2/2023.

LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 2 resident and 2 staff files, including criminal record clearances. The first aid kit was checked and is complete.
LPA requested the following documents to be submitted via email by 6/3/2023: LIC 400, Copy of Surety Bond, LIC 500, LIC 610D, and the facility sketch.

Deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit inter view conducted with and appeal rights given.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023
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 3


Document Has Been Signed on 05/23/2023 12:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: CARING HANDS A RESIDENTIAL FACILITY
FACILITY NUMBER: 502701007

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/24/2023
Section Cited
CCR
87303(e)(2)

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(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
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The Facility will lower hot water heater today and test the hot water for 3 days. Please send hot water temperature reading to LPA.
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Hot water temperature was measured at 122.8 degrees Fahrenheit in resident bathroom sink, which is not within the required range of 105 to 120 degrees.
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Type A
05/24/2023
Section Cited
CCR87203

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All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by observation:
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The facility will remove the beds, personal items, nightstands etc.. and or request that the fire marshal approve these areas for sleeping areas for the staff by POC date 5/24/23.
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two areas one is label as an office and the other is a storage room used as staff room which are not approved areas used for staff rooms
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The Administrator will inform the department of the facilities intentions for this violation by email or fax also by POC date 5/24/23
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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/23/2023 12:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: CARING HANDS A RESIDENTIAL FACILITY
FACILITY NUMBER: 502701007

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/24/2023
Section Cited
CCR
87468.2(a)(1)

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Additional Personal Rights of Residents in Privately Operated Facilities: To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups. This requirement is not met as evidenced by
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The facility will request a wavier from the department if the facility wishes to or chooses to keep the camera in R1's room.
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camera located in the bedroom with a monitor located in the non-approved staff room / Office closet.
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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023
LIC809 (FAS) - (06/04)
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