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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201439
Report Date: 01/14/2025
Date Signed: 01/14/2025 01:20:15 PM

Document Has Been Signed on 01/14/2025 01:20 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SACRED HANDS LIVINGFACILITY NUMBER:
079201439
ADMINISTRATOR/
DIRECTOR:		PANESAR, RAJWANTFACILITY TYPE:
740
ADDRESS:2980 BLUMEN AVETELEPHONE:
(925) 392-8652
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 5DATE:
01/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Charmaine Walters Givans, Care StaffTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On 01/14/2025 at 8:50AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Caregiver Charmaine Walters Givans, spoke with Administrator, Rajwant K. Panesar via telephone, and explained the purpose of the visit. Administrator arrived at 10:00AM and currently holds a certificate (#7014378740) that expires on 12/18/2025 per CDSS portal. The facility’s fire clearance was approved for six (6) non-ambulatory residents.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of six (6) bedrooms and three (3) bathrooms. All outdoor and indoor passageways are kept free of obstruction. LPA did not observe any bodies of water. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPA 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 100.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 07/22/2024. Emergency Disaster Plan was last posted on 12/2024. First aid kit was observed to be complete. Fire drill was last conducted on 12/29/2024.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SACRED HANDS LIVING
FACILITY NUMBER: 079201439
VISIT DATE: 01/14/2025
NARRATIVE
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Continued from LIC809.

Four (4) staff records were reviewed, all staff records were complete. LPA reviewed five (5) resident records, and they were current and complete. LPA reviewed a sample of medication during visit.

LPA requested the following documents to be submitted to CCLD by 01/21/2025.

· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (last page)
· Liability Insurance

LPA observed the following deficiencies during visit:
  • At: 9:15AM, LPA observed personnel and residents' files weren't available at facility for licensing to inspect.
  • At 10:00AM, LPA observed during facility tour the single car garage has been converted into staff bedroom with a bed, suitcases, sofa, laundry detergent and hygiene products.
  • At 10:15AM, LPA observed during facility tour a locked pantry door in kitchen with food, knives(sharps), and medications.
  • At 10:21AM, LPA observed during tour facility side gate were locked. Staff removed lock during inspection. Civil penalty of $500 is being assessed.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.


Exit interview conducted a copy of this report, LIC421IM, and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/14/2025 01:20 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 01/14/2025 at 12:08 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: SACRED HANDS LIVING
FACILITY NUMBER: 079201439

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
80020 Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above by locking emergency side gate without fire clearance for locked parameter which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/15/2025
Plan of Correction
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2
3
4
Staff removed lock during inspection. Deficiency cleared.

Civil penalty of $500 is being assessed.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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2
3
4
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/14/2025 01:20 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 01/14/2025 at 12:10 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: SACRED HANDS LIVING
FACILITY NUMBER: 079201439

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(3)
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:
3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.

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 in having nonperishable foods locked in a pantry located in the kitchen which poses an immediate personal rights risk to persons in care.
POC Due Date: 01/15/2025
Plan of Correction
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Administrator and Care Staff immediately removed the sharps and medications to a locked closet. Deficiency cleared during visit.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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2
3
4
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/14/2025 01:20 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 01/14/2025 at 12:15 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: SACRED HANDS LIVING
FACILITY NUMBER: 079201439

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(f)
87412 Personnel Records
f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in not having personnel files available for licensing to inspect which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2025
Plan of Correction
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Administrator will send a self certifying email to CCLD by POC stating personnel files will be available for licensing to inspect during business hours.
Type A
Section Cited
CCR
87506(d)
87506 Resident Records
(d)All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in not having residents' files available for licensing to inspect during business hours which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2025
Plan of Correction
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Administrator will send a self certifying email to CCLD by POC stating residents files will be available for licensing to inspect during business hours.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


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Document Has Been Signed on 01/14/2025 01:20 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 01/14/2025 at 12:33 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: SACRED HANDS LIVING
FACILITY NUMBER: 079201439

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
87305 Alterations to Existing Building or New Facilities

(a) Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in notifying CCLD of any alterations which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/21/2025
Plan of Correction
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Administrator agreed to submit a LIC200 and updated facility sketch to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
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