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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202749
Report Date: 11/22/2021
Date Signed: 11/22/2021 03:55:28 PM

Document Has Been Signed on 11/22/2021 03:55 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:CARING HANDS RESIDENTIAL LIVING IIFACILITY NUMBER:
435202749
ADMINISTRATOR:OKORO, SYLVESTER OFACILITY TYPE:
740
ADDRESS:1324 BAGELY WAYTELEPHONE:
(614) 747-3443
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY: 6CENSUS: 3DATE:
11/22/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Andrea ThompsonTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst Ryker Heberle (LPA) visited the facility to conduct an unannounced complaint investigation. LPA met with facility staff member Andrea Thompson (S1). During phone call with Administrator Sylvester Okoro (Admin), Admin granted permission for S1 to sign written reports on his behalf.

During tour of the facility, LPA observed a lock on the facility refrigerator. LPA took pictures of the locked refrigerator. In telephone call with Admin, Admin stated that facility staff placed a lock on the refrigerator on the recommendation of a resident's VA nurse. LPA asked Admin whether or not he had any written documentation, such as doctor's or nurse's orders recommending the use of a lock. Admin stated that he did not, and that the recommendation was received verbally.

While inspecting resident rooms, LPA observed medication visible and accessible to resident in room 3. Visible medication was confirmed to belong to the resident residing in room 3 (R1). Records review of R1'a physician's report indicates that R1 cannot administer or store his/her own medications.

Deficiencies cited. See LIC 809-D. Exit interview was conducted with S1. A copy of this report along with facility's appeal rights were provided during visit.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/22/2021 03:55 PM - It Cannot Be Edited


Created By: Ryker Heberle On 11/22/2021 at 02:48 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CARING HANDS RESIDENTIAL LIVING II
FACILITY NUMBER: 435202749

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
11/29/2021
Section Cited
CCR
87468.1(a)(3)

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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... other actions of a punitive nature, such as... interfering with daily living functions such as eating. This requirement was not met as evidenced by:
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Licensee is to remove locks from food refirgeration and freezer units. Licensee shall provide photo documentation of removed locks to the department by POC due date.
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Based on observation, the licensee did not comply with the section cited above due to refrigeration unit possessing a lock which poses a potential health, safety or personal rights risk to persons in care.
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Request Denied
Type B
11/29/2021
Section Cited
CCR87465(h)(2)

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87465(h)(2) - Incidental Medical and Dental Care - ...(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.
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Licensee to submit written plan of action and proof of correction to CCLD by POC due date.
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This requirement was not met as evidenced by: LPA observed resident medication visible and accesible in resident room. This poses a potential risk to the health and safety of residents in care.
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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:Sarah Yip
LICENSING EVALUATOR NAME:Ryker Heberle
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2021


LIC809 (FAS) - (06/04)
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