079200561-8-11-2022-15-AS-LFRO-CH7R9G-20220811124930

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200561
Report Date: 08/11/2022
Date Signed: 08/11/2022 12:49:54 PM

Document Has Been Signed on 08/11/2022 12:49 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	SERVING HANDS LLC		FACILITY NUMBER:	079200561
ADMINISTRATOR:	ESTAVILLO, MARIA LUISA		FACILITY TYPE:	740
ADDRESS:	245 LA PERA CIRCLE		TELEPHONE:	(925) 838-7736
CITY:	DANVILLE	STATE: CA	ZIP CODE:	94526
CAPACITY:	6	CENSUS: 6	DATE:	08/11/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Maria Estavillo, Administrator		TIME COMPLETED:	01:05 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 8/11/2022 at 10:35 AM, Licensing Program Analysts (LPAs) L. Francisco and P. Watson arrived unannounced to conduct Infection Control Inspection. LPAs met with Administrator, Maria Estavillo and explained the purpose of the visit. During the Infection Control Inspection, LPA toured facility with Administrator including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette and hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, paper towel and trash bin with touchless lids. Facility staff were observed to be wearing proper PPE. PPEs are maintained at central location and easily accessible for staff. At 11:45 AM, LPAs reviewed 3 staff records and 3 of 3 have health screening and TB test on file. Facility has a mitigation plan and maintains record of routine screening for residents and staff. THE FOLLOWING DEFICIENCIES WERE OBSERVED: -At 10:45 AM, LPAs observed two perishable orange juice being stored in pantry shelf in the garage. Deficiency cleared during visit. Administrator removed items and discarded it. -At 10:55 AM, LPAs observed R1 and R2 have oxygen in use. However, no oxygen signs were posted. Deficiency cleared during visit. LPAs observed Administrator post "Oxygen in-use" sign at appropriate areas -At 10:58 AM, LPAs observed R1 has 5 oxygen tanks stored inside the bedroom closet without proper stands. REPORT CONTINUES ON 809C

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

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 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SERVING HANDS LLC	FACILITY NUMBER: 079200561
	VISIT DATE: 08/11/2022

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

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 8/22/2022:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

LIC809 (FAS) - (06/04)

Page: 5 of 7

Document Has Been Signed on 08/11/2022 12:49 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SERVING HANDS LLC	FACILITY NUMBER: 079200561
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87618(b)(3)(B)

87618(b)(3)(B) Oxygen Administration - Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (B) "No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPAs did not observe oxygen in-use sign in the appropriate areas which poses an immediate health and safety risk to persons in care.
	POC Due Date: 08/12/2022
	Plan of Correction
1 2 3 4	Deficiency cleared during visit. LPAs observed Administrator post oxygen in-use signs in the appropriate areas. In addition, Administrator will review regulation and submit self-certification letter to CCL by 8/19/2022.

Type A

Section Cited

CCR

87555(b)(28)

87555(b)(28) General Food Service Requirements (b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPAs observed two perishable orange juice being stored in pantry shelf in the garage which poses an immediate health and safety risk to persons in care.
	POC Due Date: 08/12/2022
	Plan of Correction
1 2 3 4	DEFICIENCY CLEARED DURING VISIT. LPAs observed Administrator removed orange juice from pantry shelf and discarded both items. In addition, Administrator will review regulation and conduct in-service training with staff, and submit a copy of training agenda with staff signature to CCL by 8/19/2022

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

LIC809 (FAS) - (06/04)

Page: 7 of 7

Document Has Been Signed on 08/11/2022 12:49 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SERVING HANDS LLC	FACILITY NUMBER: 079200561
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87618(b)(3)(E)

87618(b)(3)(E) Oxygen Administration - Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (E) Oxygen tanks that are not portable shall be secured in a stand or to the wall. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPAs observed R1's five oxygen tanks are not stored in proper stands which poses a potential health and safety risk to persons in care.
	POC Due Date: 08/15/2022
	Plan of Correction
1 2 3 4	By POC date, Administrator agrees to obtain a stand for R1's oxygen tanks and submit a photo to CCL.

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

LIC809 (FAS) - (06/04)

Page: 6 of 7