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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201132
Report Date: 03/24/2022
Date Signed: 03/24/2022 03:42:15 PM

Document Has Been Signed on 03/24/2022 03:42 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:
03/24/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Elena Mihale, applicant and Flavian Mihale, staff TIME COMPLETED:
01:20 PM
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On 3/24/2022, LPA’s (Licensing Program Analysts) L. Ibo and K. Nguyen arrived unannounced to conduct continuation pre-licensing inspection due to a change of ownership. LPAs met with applicant Elena Mihale. NO resident 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 toured the facility to check all the deficiencies cited on March 1, 2022.

The following deficiencies was cleared during the visit:

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. CLEARED

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 . CLEARED

Continued to next page LI809C….

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2022
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 2
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: 03/24/2022
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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. CLEARED

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

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

Bedroom #6 was set up as a nursery room. CLEARED

Bedroom #5 was set up as storage room. CLEARED

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. CLEARED

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

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

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

Staff room and bathroom was being use by the new property owner; window screen was ripped. CLEARED

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

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. CLEARED

Component III completed.

No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted with Applicant and a copy of report provided.

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

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
LIC809 (FAS) - (06/04)
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