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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006343
Report Date: 02/21/2025
Date Signed: 02/21/2025 04:27:42 PM

Document Has Been Signed on 02/21/2025 04:27 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:HEILEND HANDS HOMEFACILITY NUMBER:
306006343
ADMINISTRATOR/
DIRECTOR:		SALAZAR, MARLYNFACILITY TYPE:
740
ADDRESS:1331 EAST GREENVIEW DRIVETELEPHONE:
(909) 904-3052
CITY:ORANGESTATE: CAZIP CODE:
92866
CAPACITY: 2CENSUS: 1DATE:
02/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Administrator Marlyn SalazarTIME VISIT/
INSPECTION COMPLETED:
04:42 PM
NARRATIVE
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Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by Administrator Marlyn Salazar after explaining the purpose for the visit. LPA observed that Administrator Marlyn Salazar has a valid Administrator's certificate which expires on May 15, 2025.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for two residents, of which one may be non-ambulatory, and has a hospice waiver for two. The facility is a single story home with six bedrooms, two of which are for residents, three bathrooms, two of which are for residents, two living rooms, a dining room, a kitchen, and an attached one car garage. LPA accompanied by the AD conducted a tour of the interior portion of the facility. On today's visit, LPA observed one residents in care and two staff present. LPA observed the resident sleeping in his respective bedroom. LPA observed the See Something, Say Something poster (PUB 475) mounted on a wall by the entryway of the facility. LPA inspected the two resident bedrooms, and they were observed to be free of any hazards. LPA observed the resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. Resident beds had clean linens and blankets. LPA observed additional linens are stored in a hallway closet. LPA inspected the two resident bathrooms. Resident bathrooms are clean. Bathrooms are equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 117.2 and 119 degrees Fahrenheit.

LPA observed the facility has a two day perishable and seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. The four burner gas stove lights unassisted. LPA observed kitchen knives are stored in a locked kitchen cabinet. LPA observed cleaning supplies and toxins are stored in a locked kitchen cabinet under the sink. CONTINUED ON LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HEILEND HANDS HOME
FACILITY NUMBER: 306006343
VISIT DATE: 02/21/2025
NARRATIVE
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A fire extinguisher is located in the kitchen and in the resident hallway. Fire extinguishers were observed to be charged and up to date on service. LPA tested the wired smoke detectors/carbon monoxide detectors which tested operational. LPA observed medications were being stored on top of a shelf in the living room. LPA observed a First Aid kit to be stored in the living room and it was observed to have all the required components. The door leading to the attached one car garage is kept locked and inaccessible to resident. The garage is used for storage.

LPA and AD conducted a tour of the exterior portion of the facility. LPA observed the exterior portion to be clear of obstructions and hazards. LPA observed a shaded outdoor seating area with furniture for resident use. The perimeter gates on the north side and southside of the facility are self-latching and can be opened in an evacuation. There are no bodies of water on the premises.

LPA reviewed the one resident files. All the required documentation were present and current in the resident file reviewed. LPA reviewed the one residents’ medication and medication records. LPA observed the facility was providing one medication to the resident without a proper Physician's order. LPA reviewed two staff files. LPA observed that Staff #2, who was present at the time of visit, does not have a proper criminal record clearance.

Based on the observations made during today's visit, deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Marlyn Salazar. A copy of the report and Appeal Rights were provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/21/2025 04:27 PM - It Cannot Be Edited


Created By: Brandon Lopez On 02/21/2025 at 04:06 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HEILEND HANDS HOME
FACILITY NUMBER: 306006343

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.17(c)(1)(A)
Licensing
(c)(1)(A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in a facility.

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 which poses an immediate health, safety or personal rights risk to persons in care. LPA observed that Staff #2, who was present at the time of visit, did not have a proper criminal record clearance.
POC Due Date: 02/24/2025
Plan of Correction
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LPA observed Staff #2 (S2) exit the premises at the time of visit. AD will review the regulations regarding criminal record clearance and submit it to LPA via email or fax by POC date.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(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 in which poses an immediate health, safety or personal rights risk to persons in care. During a tour of the physical plant, LPA observed that medications were being stored in a bin on top of a shelf in the living room. The medication bin was not kept in a locked secured area and could be accessible to the resident in care.
POC Due Date: 02/24/2025
Plan of Correction
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AD removed the medication during the visit. LPA observed the AD store the medication in a locked storage cabinet in the living room. POC cleared at time of visit.
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:Sheila Santos
LICENSING EVALUATOR NAME:Brandon Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/21/2025 04:27 PM - It Cannot Be Edited


Created By: Brandon Lopez On 02/21/2025 at 04:06 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HEILEND HANDS HOME
FACILITY NUMBER: 306006343

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

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 which poses an immediate health, safety or personal rights risk to persons in care. LPA observed the facility was providing a Triple Action Joint Health vitamin to Resident #1 (R1) without a physician's order. LPA observed the vitamin to be stored with the routine medications.
POC Due Date: 02/24/2025
Plan of Correction
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AD immediatey removed the medication from the routine medication bin. LPA observed the AD destroy the medication during the visit. POC cleared at time of visit.
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:Sheila Santos
LICENSING EVALUATOR NAME:Brandon Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2025


LIC809 (FAS) - (06/04)
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