<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701007
Report Date: 05/20/2024
Date Signed: 05/20/2024 01:31:05 PM

Document Has Been Signed on 05/20/2024 01:31 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CARING HANDS A RESIDENTIAL FACILITYFACILITY NUMBER:
502701007
ADMINISTRATOR/
DIRECTOR:		ACEDO, MARIA CRISTINAFACILITY TYPE:
740
ADDRESS:2912 WESTPORT CIRCLETELEPHONE:
(209) 549-6945
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY: 6CENSUS: 2DATE:
05/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Maria Christina AcedoTIME VISIT/
INSPECTION COMPLETED:
01:45 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
On 5/20/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required one year annual visit. LPA Jensen met with Administrator Maria Christina Acedo and explained the purpose of today's visit. The Inspection tool was used during the course of this process.

LPA Jensen toured the grounds. The grounds were observed to be maintained and paths were free of obstruction. There are no bodies of water on the property. All window screens were observed to be in good repair. There is a shaded area and patio furniture for client use. The covered patio arae in the backyard has durable medical equipment that is not in use being stored. LPA Jensen observed the latch on the backyard gate to be inoperable. The latch is secured with 2 screws, 1 of which is missing causing the latch to hang out of place unless manually secured. A photo of the broken latch was taken. Technical assistance was provided.

LPA Jensen toured the physical plant. The facility is licensed for 6 residents of which all may be non-ambulatory and all may be on hospice. There are currently 2 residents, both of which are on hospice. All required postings were observed to be prominently displayed. Upon entering the facility LPA Jensen was directed to work at a desk that is situated between the kitchen and the living room. On the desk was a monitor for a surveillance system that monitors a resident's bed. LPA Jensen instructed care staff to remove the surveillance equipment from the resident's private bedroom. The facility was previously cited for using a surveillance monitor in a private bedroom on 5/23/23.

LPA Jensen interviewed the care provider and was advised that medication is prepared for residents. LPA Jensen requested to see the medication and observed that residents have their medication pre-poured in to weekly pill packs by staff. The pill packs are individually labeled with the resident's name and have an AM, afternoon and PM allocation.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2024
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: CARING HANDS A RESIDENTIAL FACILITY
FACILITY NUMBER: 502701007
VISIT DATE: 05/20/2024
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
26
27
28
29
30
31
32
LPA Jensen inspected the kitchen and observed medication, cleaning supplies and knives to be locked and inaccessible to residents in care. There was a 2 day supply of perishable food observed and a 7 day supply of non-perishable food food.

The facility was observed to be sanitary and free of odor. There was an adequate supply of linens on hand. All rooms were adequately furnished and the furnishings were in good repair. There are night lights available in the hallway. The bathrooms were equipped with grab bars and non-slip flooring in bath or shower area. The bathroom water temperature was measured at 107 degrees Fahrenheit and is in compliance. The first aid kit was observed to be complete. The facility has a generator available for emergency use. The Emergency Disaster Plan was reviewed and is in compliance. The fire extinguisher was last serviced in March of 2024 and is in compliance. The smoke detector and carbon monoxide detector were determined to be in good working order. Quarterly fire drills are being conducted.

LPA Jensen reviewed 3 of 3 staff files and determine them to be complete and in compliance. LPA Jensen reviewed 2 of 2 client files and determined them to be complete.

LPA Jensen reviewed the liability insurance and verified that it is current and meets the minimum required liability limits. LPA Jensen received copies of the LIC 500, LIC 308 and insurance.

Deficiencies are being cited pursuant to the California Code of Regulations (CCR) Title 22, Division 6.

An exit interview was conducted and a copy of this report, a confidential names list and appeal rights were provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 05/20/2024 01:31 PM - It Cannot Be Edited


Created By: Maja Jensen On 05/20/2024 at 01:03 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.2(a)(1)

...residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:

(1) 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:
Deficient Practice Statement
1
2
3
4
Based on LPA Jensen's observation of a surveillance camera in a resident bedroom with a monitor displayed on the desk in the main living area, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2024
Plan of Correction
1
2
3
4
The camera was immediately disconnected. No further plan of correction is required.
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:Lisa Rios
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/20/2024 01:31 PM - It Cannot Be Edited


Created By: Maja Jensen On 05/20/2024 at 01:12 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Jensen's observation of pre-poured medication for opne week, the licensee did not comply with the section cited above in 2 of 2 counts which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2024
Plan of Correction
1
2
3
4
The Licensee agrees to conduct medication management training and submit proof of correction to the Department by the Plan of Correction due date.
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:Lisa Rios
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024


LIC809 (FAS) - (06/04)
Page: 6 of 6