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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201132
Report Date: 04/18/2024
Date Signed: 04/18/2024 02:48:52 PM

Document Has Been Signed on 04/18/2024 02:48 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 HANDS, LLCFACILITY NUMBER:
019201132
ADMINISTRATOR/
DIRECTOR:		MIHALE, ELENAFACILITY TYPE:
740
ADDRESS:8552 BRIARWOOD LANETELEPHONE:
(408) 509-0614
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY: 6CENSUS: 3DATE:
04/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Luciana Arellano, Licensee
Elena Mihale, Administrator		TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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On 4/18/2024 at 8:45 AM, Licensing Program Analysts (LPA) K. Nguyen and G. Luk arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with facility Administrator, Elena Mihale and explained the purpose of the visit. Licensee, Luciana Arellano arrived 30 minutes later.

LPAs toured facility with Elena including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 3 bedrooms are occupied by the residents and 2 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 68 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 116 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats.

At 11:00 AM, LPAs reviewed 3 clients records. At 11:30AM, LPAs reviewed 2 staff records. At 1:00PM, LPAs reviewed a sample of resident’s medications.

During the inspection deficiency was observed:

At 9:20AM, LPAs observed unlocked knifes in the sink and cabinet, unlocked cleaning supplies under sink and bug spray on the side of the refrigerator. Administrator locked up the knives, cleaning supplies and bug spray during inspection.

At 9:25AM, LPAs observed unlocked medications in the refrigerator and cabinet. Administrator locked up the medications during inspection.

At 9:30AM, LPAs observed window screen in staff room and bathroom fan is in disrepair. LPAs also observed dog feces in the side and back yard. Administrator cleaned up the dog feces during inspection.

Report continued on LIC 809c...

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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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Document Has Been Signed on 04/18/2024 02:48 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 04/18/2024 at 01:10 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: HELPING HANDS, LLC
FACILITY NUMBER: 019201132

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, the licensee did not comply with the section cited above by having cleaning supplies, bug spray, and knives left unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
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Administrator has locking up the cleaning supplies, bug spray, and knives during inspection.

Deficiency cleared.
Type A
Section Cited
CCR
87465(h)(2)
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having unlocked medications in the refrigerator and cabinet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Administrator locked up medication during inspection.

Deficiency Cleared
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:Bennett Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 04/18/2024 02:48 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 04/18/2024 at 01:10 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: HELPING HANDS, LLC
FACILITY NUMBER: 019201132

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, and record review, the licensee did not comply with the section cited above by not having a current liability insurance in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Administrator will submit a current liability insurance to CCLD by the POC date.
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above by having resident bathroom fan and window screen in disrepair and dog feces in the backyard which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Administrator cleaned dog feces during inspection. Administrator will submit picture of fix screen, and bathroom vent to CCLD by the POC date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 04/18/2024 02:48 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 04/18/2024 at 01:10 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: HELPING HANDS, LLC
FACILITY NUMBER: 019201132

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above expired non-perishable food supplies which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Administrator removed the expired can goods during inspection.

Deficiency cleared.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having pre-admission appraisal and re-appraisal completed for residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Administrator has agreed to obtain re-appraisal for all residents and submit copies to CCLD by POC date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/18/2024 02:48 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 04/18/2024 at 01:58 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: HELPING HANDS, LLC
FACILITY NUMBER: 019201132

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.2(a)
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having video baby monitors in all resident's rooms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Administrators removed the video baby monitor during inspection. Administrator will start using call button.

Deficiency cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
Page: 9 of 10
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, LLC
FACILITY NUMBER: 019201132
VISIT DATE: 04/18/2024
NARRATIVE
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At 9:45AM, LPAs observed expired can goods in cabinets. Administrator threw away expired can goods during inspection.

At 9:55AM, LPAs observed video baby monitor in all resident's rooms. Administrator removed the baby cameras during inspection and will start using call buttons.

At 11:30AM, LPAs observed residents do not have preplacement appraisals and needs & service plans.

At 12:00PM, LPAs observed liability insurance policy in 2023 was TBD. LPAs were informed by licensee that policy was canceled at the end of 2023 and is in the process of obtaining liability current insurance.


The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and Health & Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted with Luciana Arellano. A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC809 (FAS) - (06/04)
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