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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201132
Report Date: 02/29/2024
Date Signed: 02/29/2024 11:56:52 AM

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
02/26/2024 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20240226143104
FACILITY NAME:HELPING HANDS, LLCFACILITY NUMBER:
019201132
ADMINISTRATOR:MIHALE, ELENAFACILITY TYPE:
740
ADDRESS:8552 BRIARWOOD LANETELEPHONE:
(408) 509-0614
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY:6CENSUS: 3DATE:
02/29/2024
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Luciana Arellano Licensee TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff, who is not a skilled professional, gave resident morphone
INVESTIGATION FINDINGS:
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On 2/29/2024 at 10:05am, Licensing Program Analyst (LPA) K. Nguyen to conduct an complaint visit for the allegation above. LPA met with Luciana Arellano Licensee and explained the purpose of the visit.

During the course of investigation, LPA conducted reviewed files, and conducted interviews. Based on the information obtained, the above allegations are SUBSTANTIATED.

Licensee admitted to LPA that facility do not have a skill professional to administer morphine to R1. R1 cannot self-administer, but POA and hospice agency is aware and gave us permission to administer the medication.

Report continues on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
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-20240226143104
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: HELPING HANDS, LLC
FACILITY NUMBER: 019201132
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
03/07/2024
Section Cited
CCR
87633(4)(B)
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Hospice Care of Terminally Ill Residents

(4) A description of the area of licensee’s responsibility for implementing the plan including, but not limited to, facility staff duties; record keeping; and communication with the hospice agency, resident’s physician, and the resident’s responsible person(s), if any. This description shall include the type and frequency of the tasks to be performed by the facility.
(B) The plan shall specify, by name or job function, the licensed health care professional on the hospice agency staff who will control and supervise the storage and administration of all controlled drugs (Schedule II - V) for the hospice client. Facility staff can assist hospice residents with self-medications without hospice personnel being present.

This requirement is not met as evidence by:
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Licensee agree to submit a self-certified indicating the understanding of the regulation by 3/7/2024.
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Based on investigation, licensee did not comply with the section cited above by not having a skill professional to administer morphine to R1.
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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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 15-AS-20240226143104
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: HELPING HANDS, LLC
FACILITY NUMBER: 019201132
VISIT DATE: 02/29/2024
NARRATIVE
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Deficiencies are being cited in violation of Title 22 California Code of Regulations. Failure to submit proof of corrections (POC's) by plan of correction due dates along with the LIC9098 Proof of Correction may result in civil penalties.

Exit interview conducted. Appeal Rights and copy of this report provided to Licensee via email at the conclusion of interview.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3