079200895-10-6-2023-15-AS-KHOS-CZ5HD6-20240103050550

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200895
Report Date: 10/06/2023
Date Signed: 10/06/2023 05:42:01 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/08/2023 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20230908113113

FACILITY NAME:	SACRED HANDS LIVING III		FACILITY NUMBER:	079200895
ADMINISTRATOR:	PANESAR, RAJWANT KAUR		FACILITY TYPE:	740
ADDRESS:	536 LAKE PARK CT		TELEPHONE:	(209) 762-2910
CITY:	OAKLEY	STATE: CA	ZIP CODE:	94561
CAPACITY:	6	CENSUS: 3	DATE:	10/06/2023
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Rajwant Panesar, Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff put locks on the facility front door handle at night time.

INVESTIGATION FINDINGS:

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On 10/06/23 at 2:30 pm, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver findings in regard to the allegation above. LPA met with Rajwant Panesar, Administrator, and explained the purpose of the visit.

During the course of investigation, LPA interviewed 2 staff. LPA was not able to interview any of the residents due to limited cognition.

On 9/15/23 LPA observed several locks on the front door that were no longer operational. LPA requested the disabled locks be removed. On 10/06/23 LPA observed the front door still has a dead bolt lock. The dead bolt does not disengage when LPA tried to open the front door using the doorknob. S2 stated that she uses thee dead bolt lock at night.

***report continues on LIC9099C**

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 15-AS-20230908113113

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SACRED HANDS LIVING III	FACILITY NUMBER: 079200895
	VISIT DATE: 10/06/2023

NARRATIVE

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***report continues LIC9099***

This agency has investigated the complaint alleging staff put locks on the front door handle at night. Based on LPA's observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.CCLD1515

Exit interview conducted, a copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20230908113113

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SACRED HANDS LIVING III	FACILITY NUMBER: 079200895
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/13/2023 Section Cited CCR 87468.1(a)(6)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities:(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6)To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night.	1 2 3 4 5 6 7	Administrator to replace the dead bolt lock on the front door ith a single action lock by POC date and send LPA a picute of the new lock.
	8 9 10 11 12 13 14	The licensee did not met the above regulation by having a deadbolt lock on the front door which poses a potential risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC9099 (FAS) - (06/04)

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