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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209222
Report Date: 04/03/2025
Date Signed: 04/03/2025 02:30:47 PM

Document Has Been Signed on 04/03/2025 02:30 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:HAND IN HAND CARE HOMEFACILITY NUMBER:
107209222
ADMINISTRATOR/
DIRECTOR:		ZAPATA, MARTHAFACILITY TYPE:
740
ADDRESS:4361 W. FREMONT AVETELEPHONE:
(559) 389-0315
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 6CENSUS: 3DATE:
04/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:08 AM
MET WITH:Martha ZapataTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the reason for the visit with Administrator (AD) Martha Zapata and Licensee Yolanda Castigador.

During this visit, LPA toured the facility inside & out. Resident rooms and common areas were clean, in good repair and contained required equipment, furnishings and lighting. LPAs observed required items in bathrooms which were clean with hot water measuring 110 degrees. LPAs observed hygiene items, paper products, towels, extra bedding, and linens which were stored and available for use. The kitchen was found to be clean, in good repair with necessary items and appliances. Knives and sharp kitchen items were locked. LPA observed required food supply, emergency food, water, and paper products. Medications are centrally stored in a locked cabinet in the kitchen. Knives, cleaning/disinfecting supplies and chemicals are locked and stored separate from food. Doors and passageways are unobstructed throughout the facility including outdoors. First aid kits contained required items.

LPAs walked the outdoors to find the grounds well-kept with clear walkways with sitting areas. Fire extinguishers were found to be charged and serviced on 1/5/25 by Jorgenson Co. LPA conducted resident and staff file reviews as well as a medication audit. Emergency Disaster and Infection Control procedures and requirements were reviewed during the inspection.



Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D from Section 87465 Incidental and Medical Care.

LPA requested the following updated forms faxed to CCLD by 4/17/25 - Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Personnel Report (LIC 500), Client Roster (LIC 9020) and Proof of current Liability Coverage.

NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Katie Brown
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/03/2025 02:30 PM - It Cannot Be Edited


Created By: Katie Brown On 04/03/2025 at 01:36 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: HAND IN HAND CARE HOME
FACILITY NUMBER: 107209222

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.

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 which poses an immediate health, safety or personal rights risk to persons in care. R1’s Prodaxa has been given but not documented on the MAR 4/1-4/3/25 and the medication count of pills is wrong. Additionally, R1 has been given Magnesium 500mg, the MAR and order on file state 400mg. Facility needs to obtain clarified orders for both medications.
POC Due Date: 04/04/2025
Plan of Correction
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Administrator (AD) has agreed to obtain clarified Physician's orders. During the visit, AD enrolled R1 in a pharmacy that provide medication in "bubble packs". AD will send a written statement that the orders are obtained and the new pharmacy set up is complete by poc date via email.
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.
Sergiy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Katie Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/03/2025 02:30 PM - It Cannot Be Edited


Created By: Katie Brown On 04/03/2025 at 02:06 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: HAND IN HAND CARE HOME
FACILITY NUMBER: 107209222

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(4)
87465 Incidental Medical and Dental Care (h)The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws….

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 abovewhich poses/posed a potential health, safety or personal rights risk to persons in care. R1 takes Blood Pressure medication in the morning and evening. The RX label states hold if less than 100 systolic. The updated order is hold if less than 80 – the label is not correct. The facility does not have complete BP monitoring ordrs.
POC Due Date: 04/17/2025
Plan of Correction
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Ad has agreed to provide inserevice to all staff assisting with residnet medications. Inservice will include medication procedures, medication documentation, centrally stored medication process, Blood Pressure testing procedure and documentation. Insrvice documentation will be provided to CCLD by poc date by email.
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.
Sergiy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Katie Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2025


LIC809 (FAS) - (06/04)
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