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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701276
Report Date: 07/26/2023
Date Signed: 07/26/2023 12:03:56 PM


Document Has Been Signed on 07/26/2023 12:03 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:GABRIELLE'S CARING HANDFACILITY NUMBER:
502701276
ADMINISTRATOR:ANTONIA, TABITHAFACILITY TYPE:
740
ADDRESS:2921 ZARAND DRTELEPHONE:
(408) 823-0358
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:6CENSUS: 4DATE:
07/26/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Tabitha Antonio TIME COMPLETED:
12:30 PM
NARRATIVE
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On 07/26/2023 at 9:40am, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a Post-Licensing Visit. LPA Pascua was met by staff members, Amore Silva and Myrna Cablco. LPA Pascua asked the staff members to go ahead and call the Facility Designated Administrator (FDA), Tabitha Antonia and inform her that CCL was present at this time. LPA was informed that FDA Antonia was unable to come to the facility at this time due to another appointment. Shortly after, LPA met with Facility Designated Representative, Maribel Armada. At the end of the visit, LPA was able to meet with FDA Tabitha Antonio.
This facility is licensed to serve and retain 6 residents who are 60 or older. All of which may be non-ambulatory. This facility also holds a Dementia Program on file and has a Hospice Waiver for 6.
Current census was 4.
LPA reviewed 4 resident files. It was learned that 1 out of 4 residents are currently obtaining services from home health. 3 out of 4 resident files were incomplete. 3 out 4 resident files did not have a Pre- Admission Appraisal. 2 out of 4 residents did not have a current appraisal on file. LPA reviewed 2 staff files. 2 out 2 staff files were complete and up to date.
LPA reviewed Medication Administration records. It was observed that all 4 resident's Medication Administration records were not signed for today's AM medication. It was observed that 1 out of 4 residents did not have medication initialed for administration from 07/23/2023-07/26/2023. It was observed that 2 out of 4 residents did not medication initialed for administration from 07/24/2023-07/26/2023. Based on interviews conducted it was learned that medication was provided during these times and staff did not initial the Medication Administration Records (MARs) during the time of administration.
LPA conducted a tour of the facility.
The fire extinguisher, located in the kitchen area, was serviced by Jorgenson Company on 02/06/2023. Carbon Monoxide and fire alarms were present and in good repair.
Common areas for resident use were toured. Furniture and furnishings were observed to be present and in compliance.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
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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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: GABRIELLE'S CARING HAND
FACILITY NUMBER: 502701276
VISIT DATE: 07/26/2023
NARRATIVE
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A tour of the bathrooms was conducted. Hot water temperatures were taken to ensure that the hot water being dispensed was within the allowed range of 105-120 degrees at this time. Grab bars were present and functional.
Resident bedrooms were toured. Furniture and furnishing were observed to be present and in good condition.
A linen closet was located in the hallway. LPA observed a sufficient amount of linens at this time.
The kitchen area was toured. Facility freezer and refrigerator showed to be functional and in compliance at this time. A tour of the pantry was conducted. LPA observed that there was a 2 day perishable and 7-day nonperishable food supply at this time.
Garage area was toured. Laundry detergent and cleaning supplies were locked and made inaccessible at this time.
First aid kit was observed to be present and contained all of the required components at this time.

The exterior of the physical plant was toured. Perimeter fence was observed to be stable and gates were in good repair with no hazards present.

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code.



An exit interview was conduct, a copy of this report and appeal rights were printed and a copy was given to the facility.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/26/2023 12:03 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: GABRIELLE'S CARING HAND
FACILITY NUMBER: 502701276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited by not ensuring that during administration of medication was maintained. LPA observed that 4 out of 4 resident medication records have not been initiated by staff during administration of medication. This poses a immediate health and safety risk to persons in care.
POC Due Date: 07/27/2023
Plan of Correction
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The facility states that a review of the section 87465(c)(3) will be conducted. In addition, a statement of correction that highlights a policy and procedure on how medication management will be processed on a daily basis.Facility shall conduct medication training to include in-service training to remind staff of medication procedures and documentation. Proof of staff training for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA's email at Arielle.pascua@dss.ca.gov by the POC date.
Type A
Section Cited
CCR
87628(a)
Diabetes
(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not ensure that proper training was conducted to administer R1's glucose. This poses an immediate health, safety, and personal rights risk to persons in care.
POC Due Date: 07/27/2023
Plan of Correction
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Licensee shall conduct proper training regarding diabetes care based on Title 22 regulations. A statement of correction along with proof of training for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA's email at arielle.pascua@dss.ca.gov by the POC date.
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: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 07/26/2023 12:03 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: GABRIELLE'S CARING HAND
FACILITY NUMBER: 502701276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records review, the Licensee did not comply with the section above by not ensuring that a pre-admission appraisal was conducted for 3 out 4 residents. This poses a potential health, safety and person rights risks to persons in care.
POC Due Date: 08/18/2023
Plan of Correction
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Licensee shall ensure that pre-admission appraisals are complete and current for all resident files. A statement of correction and understanding shall be completed for the section cited and be provided to the LPA by the POC date.
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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4