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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200895
Report Date: 09/15/2026
Date Signed: 09/24/2026 02:49:24 PM

Document Has Been Signed on 09/24/2026 02:49 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SACRED HANDS LIVING IIIFACILITY NUMBER:
079200895
ADMINISTRATOR/
DIRECTOR:		PANESAR, RAJWANT KAURFACILITY TYPE:
740
ADDRESS:536 LAKE PARK CTTELEPHONE:
(209) 762-2910
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 2DATE:
09/15/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:14 PM
MET WITH:Nisha Kerr, Caregiver TIME VISIT/
INSPECTION COMPLETED:
08:00 PM
NARRATIVE
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**This is an Amended Report**

On 09/24/2026 at 1:45PM, Licensing Program Analyst (LPA),T. Syess-Gibson arrived unannounced to amend report previously issued on 09/15/2026. During visit on 09/15/2026, LPA did observed facility had 7- days of non perishable food and 2- days of perishables food. LPA met with Shedra Jackson, Caregiver and explained purpose of visit and provided this report.

On 09/15/2026 at 1:14PM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct a 1-Year Required inspection. LPA met with Nisha Kerr, Caregiver and explained the purpose of the visit. Rajwant Panesar, Administrator arrived at 1:46pm. The fire clearance was approved for four (4) ambulatory, one (1) non ambulatory and one (1) bedridden resident. LPA observed two (2) residents during visit.

LPA toured the facility with caregiver including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of five (5) bedrooms and two (2) bathrooms. All outdoor and indoor passageways are kept free of obstruction. LPA did not observe any bodies of water. A comfortable temperature is maintained at 77 degrees Fahrenheit. LPA observed one room with two beds; the other rooms are empty. The hot water temperature in the resident’s shared bathroom was measured at 118.1 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and nonskid mats. Facility has 2-day of perishable food and 7 days of non-perishable food supply, LPA advised Administrator that once facility has new residents this regulation should be followed.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 05/14/2026. Emergency Disaster Plan was last posted 07/10/2026. First aid kit was observed to be complete. Facility has no record of fire drill being conducted.

Continued LIC809C….

Harpreet Humpal
Tonica Syess-Gibson
DATE: 09/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2026
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 12
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SACRED HANDS LIVING III
FACILITY NUMBER: 079200895
VISIT DATE: 09/15/2026
NARRATIVE
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Continued from LIC809

Three (3) staff files were reviewed, S3 is missing health screening /TB and FirstAid. LPA reviewed two (2) resident’s files were reviewed, which were current and complete. LPA also reviewed medications during visit.

The following forms to be updated and submitted to CCLD by 09/22/2026:

  • LIC500- Personnel Report
  • LIC308- Designation of Facility Responsibility
  • LIC610E- Emergency/Disaster Plan including infection control plans
  • Evidence of Liability Insurance
  • Administrator Certificate
  • LIC501 Personnel Record
  • Letter from Licensee board of resolution (include facility’s name, facility number and address
  • Copy of new administrator’s ID/DL
  • LIC 9182 or fingerprinting and background check

Continue on LIC809C……

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Tonica Syess-Gibson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SACRED HANDS LIVING III
FACILITY NUMBER: 079200895
VISIT DATE: 09/15/2026
NARRATIVE
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Continued from LIC809C

The following deficiencies were observed during the visit:

  • At 1:34PM, LPA observed bedroom#1 does not have a bed, chair, night stand, chest of drawers
  • At 1:35PM, LPA observed facility does not have nonskid mat in one (1) of the two (2) bathtub/shower
  • At 1:38PM, LPA observed bedroom#2 does not have a night stand and chair
  • At 1:39PM, LPA observed bedroom#3 does not have a chest of drawer
  • At 1:40PM, LPA observed bedroom#4 does not have a chest of drawer
  • At 1:43PM, LPA observed facility passageway to emergency exit gate was not free of obstruction
  • At 1:43PM, LPA observed facility’s window screens were not clean
  • At 1:45PM, LPA observed facility has two (2) HOYER lifts in the garage, LPA was informed by Administrator one is for R1 and the other was for a resident no longer at facility.
  • At 1:48PM, LPA observed bedroom#5, has a bed, pillow, covers, mirror, clothes, shoes, lamp and a suitcase inside closet located in bathroom
  • At 1:49PM, LPA observed Lysol all purpose cleaner under kitchen cabinet
  • At 2:00PM, LPA observed facility did not submit a death report for R3
  • At 3:43PM, LPA observed during file review facility does not have Dr. orders for R1’s ½ bedrails and HOYER lift.

Continued on LIC809C.....

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Tonica Syess-Gibson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026
LIC809 (FAS) - (06/04)
Page: 4 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SACRED HANDS LIVING III
FACILITY NUMBER: 079200895
VISIT DATE: 09/15/2026
NARRATIVE
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Continued from LIC809C


  • At 3:38PM, LPA observed facility’s Administrator does not hold a current Administrator Certificate
  • At 3:52PM, LPA observed S3 does not have a health screening/ TB and FirstAid

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal rights and a copy of this report were provided to Rajwant Panesar.

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Tonica Syess-Gibson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026
LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 09/15/2026 07:40 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 09/15/2026 at 06:14 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SACRED HANDS LIVING III
FACILITY NUMBER: 079200895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2026
Section Cited
CCR
87303(c)

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87303 Maintenance and Operation (c) All window screens shall be clean and maintained in good repair.
This requirement is not met as evidenced by:

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Licensee agreed to clean window screens and send CCLD an email photo by POC date.
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Based on observation, the licensee did not comply with the section cited above in not having window screens cleaned which poses a potential health and personal rights risk to persons in care.
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Type B
09/25/2026
Section Cited
CCR87307(2)(C)

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(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements:(C)No bedroom of a resident shall be used as a passageway to another room, bath or toilet.This requirement is not met as evidenced by:
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Licensee agreed to remove items from bedroom#5/bathroom closet and send photo email to CCLD by POC date.
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Based on observation, the licensee did not comply with the section cited above in having bed, pillow, covers, mirror, clothes, shoes, lamp and a suitcase inside closet in bedroom#5/bathroom, which poses a potential personal rights risk to persons in care.
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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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Tonica Syess-Gibson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2026


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 09/15/2026 07:40 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 09/15/2026 at 06:24 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SACRED HANDS LIVING III
FACILITY NUMBER: 079200895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2026
Section Cited
CCR
87307(B)

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(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. This requirement is not met as evidenced by:
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Licensee agreed to read the regulation, furnish all rooms as per requirement and send a photo email to CCLD by POC date.
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Based on observation, the licensee did not comply with the section cited above in not having required bedroom furniture in all rooms which poses a potential personal rights risk to persons in care.
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Type B
09/25/2026
Section Cited
CCR87303(e)(5)

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(e) Water supplies and plumbing fixtures shall be maintained as follows:(5)Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors. This requirement is not met as evidenced by:
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Licensee agreed to place slip- resistant mats in all bathtubs and showers. Licensee will send photo email to CCLD by POC date.
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Based on observation, the licensee did not comply with the section cited above in not having slip resistant mats in all bathtubs and showers which poses a potential safety and personal rights risk to persons in care.
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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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Tonica Syess-Gibson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2026


LIC809 (FAS) - (06/04)
Page: 7 of 12
Document Has Been Signed on 09/15/2026 07:40 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 09/15/2026 at 06:35 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SACRED HANDS LIVING III
FACILITY NUMBER: 079200895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2026
Section Cited
CCR
87211(a)(1)

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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) ...This requirement is not met as evidenced by:
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Licensee agreed to read regulation 87211 and send a self certifying email to CCLD by POC date.
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Based on record review, the licensee did not comply with the section cited above in not furnish to licensing agency R3's death report which poses a potential personal rights risk to persons in care.
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Type B
09/25/2026
Section Cited
CCR87307(d)(6)

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 (d)The following space and safety provisions shall apply to all facilities: (6)All outdoor and indoor passageways and stairways shall be kept free of obstruction.This requirement is not met as evidenced by:
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Licensee agreed to implement a plan and send plan to CCLD by POC date.
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Based on observation, the licensee did not comply with the section cited above in not having outdoor passageway free from obstruction which poses a potential health, safety and personal rights risk to persons in care.
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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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Tonica Syess-Gibson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/15/2026 07:40 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 09/15/2026 at 06:44 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SACRED HANDS LIVING III
FACILITY NUMBER: 079200895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2026
Section Cited
CCR
87608(a)(3)

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(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal...... (3) A written order from a physician indicating the need for the postural support...This requirement is not met as evidenced by:
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Licensee agreed to obtain a written order from R1's physician for 1/2 bedrails and HOYER lift. Licensee will send copy of orders to CCLD by POC date.
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Based on record review, the licensee did not comply with the section cited above in not having R1's written order from physician for 1/2 bed rails and HOYER lift which poses a safety or personal rights risk to persons in care
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Type B
09/25/2026
Section Cited
CCR87405(a)

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(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient number of hours... This requirement is not met as evidenced by:
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Licensee agreed to designate an administrator and send all documents to CCLD by POC date.
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Based on record review, the licensee did not comply with the section cited above in not having a qualified and currently certified administrator which poses a potential health, safety or personal rights risk to persons in care
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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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Tonica Syess-Gibson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/15/2026 07:40 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 09/15/2026 at 06:58 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SACRED HANDS LIVING III
FACILITY NUMBER: 079200895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2026
Section Cited
CCR
87411(c)(1)

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(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
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Licensee agreed to have S3 complete FirstAid training and send copy of certificate via email to CCLD by POC date.
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Based on record review, the licensee did not comply with the section cited above in not having S3 FirstAid which poses a potential health, safety or personal rights risk to persons in care
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Type B
09/25/2026
Section Cited
CCR87411(f)

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(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician....This requirement is not met as evidenced by:
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Licensee agrees to have S3 obtain a health screening and TB. Licensee will send copy via email to CCLD by POC date.
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Based on record review, the licensee did not comply with the section cited above in not having S3 health screening /TB which poses a potential health, safety or personal rights risk to persons in care
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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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Tonica Syess-Gibson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/15/2026 07:40 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 09/15/2026 at 07:05 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SACRED HANDS LIVING III
FACILITY NUMBER: 079200895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2026
Section Cited
HSC
1569.69(c)

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(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. ...This requirement is not met as evidenced by:
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Licensee will implement a plan and send plan to CCLD by POC date.
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Based on record review, the licensee did not comply with the section cited above in not having a quarterly fire drill which poses a potential health, safety or personal rights risk to persons in care
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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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Tonica Syess-Gibson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2026


LIC809 (FAS) - (06/04)
Page: 11 of 12
Document Has Been Signed on 09/15/2026 07:40 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 09/15/2026 at 07:09 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SACRED HANDS LIVING III
FACILITY NUMBER: 079200895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2026
Section Cited
CCR
87309(a)

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(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage...This requirement is not met as evidenced by:.
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Licensee immediately removed Lysol form unlocked kitchen cabinet and place din locked storage. Deficiency cleared during visit.
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Based on observation, the licensee did not comply with the section cited above in not having disinfectants, cleaning solutions in a locked storage which poses a potential health or safety risk to persons in care
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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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Tonica Syess-Gibson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2026


LIC809 (FAS) - (06/04)
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