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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201132
Report Date: 03/01/2022
Date Signed: 03/01/2022 07:28:57 PM

Document Has Been Signed on 03/01/2022 07:28 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:HELPING HANDSFACILITY NUMBER:
019201132
ADMINISTRATOR:MIHALE, ELENAFACILITY TYPE:
740
ADDRESS:8552 BRIARWOOD LANETELEPHONE:
(408) 509-0614
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY: 6CENSUS: 0DATE:
03/01/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Elena Mihale, Administrator, Antonia Arellano, licensee TIME COMPLETED:
07:50 PM
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On 3/1/2022, Licensing Program Analysts (LPAs) L. Ibo & K. Nguyen arrived unannounced pre-licensing for change of ownership. LPAs met with Administrator Elena Mihale.Licensee Antonia Arellano arrived around 6:45PM. LPAs explained the purpose of the visit. No residents observed during the visit.

Facility has an approved fire clearance for 6 non ambulatory residents. Last fire inspection was conducted on 1/22/2022. LPAs inspected the facility including but not limited to 6 resident rooms, 1 staff room, 1 staff bathroom and 3 residents’ bathrooms, common areas, kitchen, dining, family room, living room, courtyard area and outside areas.

LPAs observed the following during the inspection:

Sticky floor

Living is unorganized with the following items; kids’ trampoline, empty boxes, cluttered shoes

Kitchen area; kitchen knives are placed on the counter; rotten fruits at the kitchen counter, unorganized and cluttered children’s toys & children’s supply, empty boxes, garbage’s, unlocked medication, flower base and old flowers with cloudy water, sink area has dirty dishes & pots and pans , dog food and dog water bowl located on the hallway

Family room; cluttered children’s toys, basket full of toys that is blocking kitchen hallway, couch pillows was unorganized

Bedroom #1; the only set up room for licensing inspection, with one bed, lamp shade, drawer, closet has multiple curtain rods and detached bedrail, lamps, unplugged TV, multiple comforter sets

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SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2022
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HELPING HANDS
FACILITY NUMBER: 019201132
VISIT DATE: 03/01/2022
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Bedroom #2; LPAs observed 1 hospital bed with open empty boxes all over the floor, pillows on top of open boxes , lamp shade on the floor, garbage bags under the hospital bed, mattress leaning on the side of the wall

Bedroom #3; LPAs observed hospital bed, per Administrator “sometimes someone rest on this room” , multiple medication that was placed on top of the bed dresser

Bedroom #4; LPAs observed 2 hospital beds, towels, tissue boxes, mop and duster and unused bedsheets on top of the bed

Bathroom adjacent to family room; LPAs observed hoyer lift, sticky flooring, unlock air freshener spray

Bedroom #6 was set up as a nursery room

Bedroom #5 was set up as storage room

Medicine cabinet is located adjacent to bedroom #5, LPAs observed that key was attached to the medicine cabinet, inside the cabinet are unorganized random first aid supplies

Bathroom right next to family room, LPAs observed unlocked disinfectant and cleaning supplies, air vent was open with missing cover/lid

Hallway next to bedroom #1, LPAs observed cleaning supplies, gallon of bleach and heavy-duty degreaser

Garage was observed to have scattered/unorganized random cleaning supplies, hoyer lift, water dispenser and etc.

Staff room and bathroom was being use by the new property owner, window screen was ripped

Courtyard; LPAs observed, wires hanging from the roof, unorganized tables and chairs

Backyard and side yard; LPAs observed screen door leaning on fence, the side of the shed had garbage bags, ladder laying on the pathway, multiple chairs observed in front of the shed, LPAs observed deck with multiple wood constructions, uneven pavement

Due to time constraint component III was not completed, LPA will re-visit facility.

LPA is not recommending facility for license until all deficiencies are cleared from facility . This Pre-Licensing report will be submitted to the Central Application Branch (CAB) for review.

Exit interview conducted with Applicant/Administrator.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC809 (FAS) - (06/04)
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