Sacred Hands Living III

Type of visit: Required - 1 Year

**This is an Amended Report** On 09/24/2026 at 1:45PM, Licensing Program Analyst (LPA),T. Syess-Gibson arrived unannounced to amend report previously issued on 09/15/2026. During visit on 09/15/2026, LPA did observed facility had 7- days of non perishable food and 2- days of perishables food. LPA met with Shedra Jackson, Caregiver and explained purpose of visit and provided this report. On 09/15/2026 at 1:14PM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct a 1-Year Required inspection. LPA met with Nisha Kerr, Caregiver and explained the purpose of the visit. Rajwant Panesar, Administrator arrived at 1:46pm. The fire clearance was approved for four (4) ambulatory, one (1) non ambulatory and one (1) bedridden resident. LPA observed two (2) residents during visit. LPA toured the facility with caregiver including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of five (5) bedrooms and two (2) 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 77 degrees Fahrenheit. LPA observed one room with two beds; the other rooms are empty. The hot water temperature in the resident’s shared bathroom was measured at 118.1 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and nonskid mats. Facility has 2-day of perishable food and 7 days of non-perishable food supply, LPA advised Administrator that once facility has new residents this regulation should be followed. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 05/14/2026. Emergency Disaster Plan was last posted 07/10/2026. First aid kit was observed to be complete. Facility has no record of fire drill being conducted. Continued LIC809C…. Continued from LIC809 Three (3) staff files were reviewed, S3 is missing health screening /TB and FirstAid. LPA reviewed two (2) resident’s files were reviewed, which were current and complete. LPA also reviewed medications during visit. The following forms to be updated and submitted to CCLD by 09/22/2026: LIC500- Personnel Report LIC308- Designation of Facility Responsibility LIC610E- Emergency/Disaster Plan including infection control plans Evidence of Liability Insurance Administrator Certificate LIC501 Personnel Record Letter from Licensee board of resolution (include facility’s name, facility number and address Copy of new administrator’s ID/DL LIC 9182 or fingerprinting and background check Continue on LIC809C…… Continued from LIC809C The following deficiencies were observed during the visit: At 1:34PM, LPA observed bedroom#1 does not have a bed, chair, night stand, chest of drawers At 1:35PM, LPA observed facility does not have nonskid mat in one (1) of the two (2) bathtub/shower At 1:38PM, LPA observed bedroom#2 does not have a night stand and chair At 1:39PM, LPA observed bedroom#3 does not have a chest of drawer At 1:40PM, LPA observed bedroom#4 does not have a chest of drawer At 1:43PM, LPA observed facility passageway to emergency exit gate was not free of obstruction At 1:43PM, LPA observed facility’s window screens were not clean At 1:45PM, LPA observed facility has two (2) HOYER lifts in the garage, LPA was informed by Administrator one is for R1 and the other was for a resident no longer at facility. At 1:48PM, LPA observed bedroom#5, has a bed, pillow, covers, mirror, clothes, shoes, lamp and a suitcase inside closet located in bathroom At 1:49PM, LPA observed Lysol all purpose cleaner under kitchen cabinet At 2:00PM, LPA observed facility did not submit a death report for R3 At 3:43PM, LPA observed during file review facility does not have Dr. orders for R1’s ½ bedrails and HOYER lift. Continued on LIC809C..... Continued from LIC809C At 3:38PM, LPA observed facility’s Administrator does not hold a current Administrator Certificate At 3:52PM, LPA observed S3 does not have a health screening/ TB and FirstAid Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal rights and a copy of this report were provided to Rajwant Panesar.the state’s words, verbatim · CDSS document, Sep 15, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(c) · Plan of correction due date: Sep 25, 2026

87303 Maintenance and Operation (c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in not having window screens cleaned which poses a potential health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee agreed to clean window screens and send CCLD an email photo by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(2)(C) · Plan of correction due date: Sep 25, 2026

(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements:(C)No bedroom of a resident shall be used as a passageway to another room, bath or toilet.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in having bed, pillow, covers, mirror, clothes, shoes, lamp and a suitcase inside closet in bedroom#5/bathroom, which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee agreed to remove items from bedroom#5/bathroom closet and send photo email to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(B) · Plan of correction due date: Sep 25, 2026

(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in not having required bedroom furniture in all rooms which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee agreed to read the regulation, furnish all rooms as per requirement and send a photo email to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(e)(5) · Plan of correction due date: Sep 25, 2026

(e) Water supplies and plumbing fixtures shall be maintained as follows:(5)Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in not having slip resistant mats in all bathtubs and showers which poses a potential safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee agreed to place slip- resistant mats in all bathtubs and showers. Licensee will send photo email to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Sep 25, 2026

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) ...This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in not furnish to licensing agency R3's death report which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee agreed to read regulation 87211 and send a self certifying email to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(d)(6) · Plan of correction due date: Sep 25, 2026

(d)The following space and safety provisions shall apply to all facilities: (6)All outdoor and indoor passageways and stairways shall be kept free of obstruction.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in not having outdoor passageway free from obstruction which poses a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee agreed to implement a plan and send plan to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Sep 25, 2026

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal...... (3) A written order from a physician indicating the need for the postural support...This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in not having R1's written order from physician for 1/2 bed rails and HOYER lift which poses a safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee agreed to obtain a written order from R1's physician for 1/2 bedrails and HOYER lift. Licensee will send copy of orders to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Sep 25, 2026

(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient number of hours... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in not having a qualified and currently certified administrator which poses a potential health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee agreed to designate an administrator and send all documents to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(1) · Plan of correction due date: Sep 24, 2026

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in not having S3 FirstAid which poses a potential health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee agreed to have S3 complete FirstAid training and send copy of certificate via email to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(f) · Plan of correction due date: Sep 25, 2026

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician....This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in not having S3 health screening /TB which poses a potential health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee agrees to have S3 obtain a health screening and TB. Licensee will send copy via email to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.69(c) · Plan of correction due date: Sep 25, 2026

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. ...This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in not having a quarterly fire drill which poses a potential health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee will implement a plan and send plan to CCLD by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Sep 16, 2026

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage...This requirement is not met as evidenced by:. Based on observation, the licensee did not comply with the section cited above in not having disinfectants, cleaning solutions in a locked storage which poses a potential health or safety risk to persons in carethe state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee immediately removed Lysol form unlocked kitchen cabinet and place din locked storage. Deficiency cleared during visit.

Type of visit: Required - 1 Year

On 09/15/2026 at 1:14PM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct a 1-Year Required inspection. LPA met with Nisha Kerr, Caregiver and explained the purpose of the visit. Rajwant Panesar, Administrator arrived at 1:46pm. The fire clearance was approved for four (4) ambulatory, one (1) non ambulatory and one (1) bedridden resident. LPA observed two (2) residents during visit. LPA toured the facility with caregiver including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of five (5) bedrooms and two (2) 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 77 degrees Fahrenheit. LPA observed one room with two beds; the other rooms are empty. The hot water temperature in the resident’s shared bathroom was measured at 118.1 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and nonskid mats. Facility does not have 2-day perishable food and one week non-perishable food supply, LPA advised Administrator that once facility has new residents this regulation should be followed. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 05/14/2026. Emergency Disaster Plan was last posted 07/10/2026. First aid kit was observed to be complete. Facility has no record of fire drill being conducted. Continued LIC809C…. Continued from LIC809 Three (3) staff files were reviewed, S3 is missing health screening /TB and FirstAid. LPA reviewed two (2) resident’s files were reviewed, which were current and complete. LPA also reviewed medications during visit. The following forms to be updated and submitted to CCLD by 09/22/2026: LIC500- Personnel Report LIC308- Designation of Facility Responsibility LIC610E- Emergency/Disaster Plan including infection control plans Evidence of Liability Insurance Administrator Certificate LIC501 Personnel Record Letter from Licensee board of resolution (include facility’s name, facility number and address Copy of new administrator’s ID/DL LIC 9182 or fingerprinting and background check Continue on LIC809C…… Continued from LIC809C The following deficiencies were observed during the visit: At 1:34PM, LPA observed bedroom#1 does not have a bed, chair, night stand, chest of drawers At 1:35PM, LPA observed facility does not have nonskid mat in one (1) of the two (2) bathtub/shower At 1:38PM, LPA observed bedroom#2 does not have a night stand and chair At 1:39PM, LPA observed bedroom#3 does not have a chest of drawer At 1:40PM, LPA observed bedroom#4 does not have a chest of drawer At 1:43PM, LPA observed facility passageway to emergency exit gate was not free of obstruction At 1:43PM, LPA observed facility’s window screens were not clean At 1:45PM, LPA observed facility has two (2) HOYER lifts in the garage, LPA was informed by Administrator one is for R1 and the other was for a resident no longer at facility. At 1:48PM, LPA observed bedroom#5, has a bed, pillow, covers, mirror, clothes, shoes, lamp and a suitcase inside closet located in bathroom At 1:49PM, LPA observed Lysol all purpose cleaner under kitchen cabinet At 2:00PM, LPA observed facility did not submit a death report for R3 At 3:43PM, LPA observed during file review facility does not have Dr. orders for R1’s ½ bedrails and HOYER lift. Continued on LIC809C..... Continued from LIC809C At 3:38PM, LPA observed facility’s Administrator does not hold a current Administrator Certificate At 3:52PM, LPA observed S3 does not have a health screening/ TB and FirstAid Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal rights and a copy of this report were provided to Rajwant Panesar.the state’s words, verbatim · CDSS document, Sep 15, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(c) · Plan of correction due date: Sep 25, 2026

87303 Maintenance and Operation (c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in not having window screens cleaned which poses a potential health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee agreed to clean window screens and send CCLD an email photo by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(2)(C) · Plan of correction due date: Sep 25, 2026

(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements:(C)No bedroom of a resident shall be used as a passageway to another room, bath or toilet.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in having bed, pillow, covers, mirror, clothes, shoes, lamp and a suitcase inside closet in bedroom#5/bathroom, which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee agreed to remove items from bedroom#5/bathroom closet and send photo email to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(B) · Plan of correction due date: Sep 25, 2026

(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in not having required bedroom furniture in all rooms which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee agreed to read the regulation, furnish all rooms as per requirement and send a photo email to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(e)(5) · Plan of correction due date: Sep 25, 2026

(e) Water supplies and plumbing fixtures shall be maintained as follows:(5)Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in not having slip resistant mats in all bathtubs and showers which poses a potential safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee agreed to place slip- resistant mats in all bathtubs and showers. Licensee will send photo email to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Sep 25, 2026

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) ...This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in not furnish to licensing agency R3's death report which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee agreed to read regulation 87211 and send a self certifying email to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(d)(6) · Plan of correction due date: Sep 25, 2026

(d)The following space and safety provisions shall apply to all facilities: (6)All outdoor and indoor passageways and stairways shall be kept free of obstruction.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in not having outdoor passageway free from obstruction which poses a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee agreed to implement a plan and send plan to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Sep 25, 2026

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal...... (3) A written order from a physician indicating the need for the postural support...This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in not having R1's written order from physician for 1/2 bed rails and HOYER lift which poses a safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee agreed to obtain a written order from R1's physician for 1/2 bedrails and HOYER lift. Licensee will send copy of orders to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Sep 25, 2026

(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient number of hours... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in not having a qualified and currently certified administrator which poses a potential health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee agreed to designate an administrator and send all documents to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(1) · Plan of correction due date: Sep 24, 2026

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in not having S3 FirstAid which poses a potential health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee agreed to have S3 complete FirstAid training and send copy of certificate via email to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(f) · Plan of correction due date: Sep 25, 2026

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician....This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in not having S3 health screening /TB which poses a potential health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee agrees to have S3 obtain a health screening and TB. Licensee will send copy via email to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.69(c) · Plan of correction due date: Sep 25, 2026

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. ...This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in not having a quarterly fire drill which poses a potential health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee will implement a plan and send plan to CCLD by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Sep 16, 2026

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage...This requirement is not met as evidenced by:. Based on observation, the licensee did not comply with the section cited above in not having disinfectants, cleaning solutions in a locked storage which poses a potential health or safety risk to persons in carethe state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee immediately removed Lysol form unlocked kitchen cabinet and place din locked storage. Deficiency cleared during visit.

Type of visit: Required - 1 Year

On 07/30/2025 at 10:00AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Administrator Rajwant Kaur Panesar and explained the purpose of the visit. The fire clearance was approved for four (4) ambulatory, one (1) non ambulatory and one (1) bedridden resident. The facility has no residents at this time. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of five (5) bedrooms and two (2) bathrooms. four (4) bedrooms for residents, one (1) staff bedroom. All outdoor and indoor passageways are kept free of obstruction. LPA did not observe any bodies of water. LPA observed no residents at the facility during the time of visit. A comfortable temperature is maintained at 76 degrees Fahrenheit. LPA observed one room with two beds; the other rooms are empty. The hot water temperature in the resident’s shared bathroom was measured at 110.5 degrees Fahrenheit. Clients’ bathrooms are equipped with grab bars and nonskid mats. Facility does not have 2-day perishable food and one week non-perishable food supply, LPA advised Administrator that once facility has new residents this regulation should be followed. Continued LIC809C. Continued from LIC809 Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 07/11/2025. Emergency Disaster Plan was last posted 06/15/2025. First aid kit was observed to be complete. No fire drill has been conducted; facility doesn't have any residents. Two (2) staff files was reviewed, Administrator advised LPA of last residents moved out in March 2021, no resident’s files were reviewed during visit. The following forms to be updated and submitted to CCLD by 08/06/2025: LIC500- Personnel Report LIC308- Designation of Facility Responsibility LIC610E- Emergency/Disaster Plan including infection control plans Evidence of Liability Insurance Administrator Certificate No Deficiencies cited during visit. Exit interview conducted and a copy of this report providedthe state’s words, verbatim · CDSS document, Jul 30, 2025

Type of visit: Required - 1 Year

On 07/22/2024 at 2:03PM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Administrator Rajwant Kaur Panesar, and explained the purpose of the visit. The facility’s fire clearance was approved for six (6) bedridden residents. The facility has no residents at this time. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of five (5) bedrooms and two (2) bathrooms. four (4 bedrooms for residents, one (1) staff bedroom. All outdoor and indoor passageways are kept free of obstruction. LPA did not observe any bodies of water. A comfortable temperature is maintained at 82 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 109.6 degrees Fahrenheit. Clients’ bathrooms are equipped with grab bars and nonskid mats. 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 06/302024. First aid kit was observed to be complete. No fire drill has been conducted; facility doesn't have any residents. Continued LIC809C. Continued from LIC809. One (1) resident file was reviewed, although there are no residents at the facility at this time. NO staff files were available for review during visit. The following deficiencies observed during visit. At 3:20PM LPA observed Administrator didn't have an Administrator Certificate or proof of payment/processing At 3:30PM during record review LPA observed One (1) out of the previous three(3) resident's files were available for review At 3:45PM during record review LPA observed there were no staff files available for review The following forms to be updated and submitted to CCLD by 07/29/2024: · · LIC 500 Personnel Report · LIC 400 Affidavit Regarding Client/Resident Cash Resources · LIC 402 Surety Bond · LIC610D Emergency Disaster Plan · LIC308 Designation of facility responsibility · Exit interview conducted and a copy of this report providedthe state’s words, verbatim · CDSS document, Jul 22, 2024

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 07/22/2024 at 2:03PM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Administrator Rajwant Kaur Panesar, and explained the purpose of the visit. Administrator advised LPA of there being no residents at the facility and that the three(3) residents were moved with their family knowledge. One (1) resident was moved to the Administrator's other facility Sacred Hands I. The other two(2) residents (husband and wife) were moved by their daughter to a facility closer to family.the state’s words, verbatim · CDSS document, Jul 22, 2024