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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201439
Report Date: 05/05/2026
Date Signed: 05/05/2026 03:51:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/08/2025 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250808150541
FACILITY NAME:SACRED HANDS LIVINGFACILITY NUMBER:
079201439
ADMINISTRATOR:PANESAR, RAJWANTFACILITY TYPE:
740
ADDRESS:2980 BLUMEN AVETELEPHONE:
(925) 392-8652
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 4DATE:
05/05/2026
UNANNOUNCEDTIME BEGAN:
01:42 PM
MET WITH:Charmaine Walters Givans, CaregiverTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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 Staff did not seek medical attention for resident in a timely manner.
Staff did not notify resident's responsible party of incident.
INVESTIGATION FINDINGS:
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On 05/05/2026 at 1:42PM, Licensing Program Analysts (LPA), T. Syess-Gibson arrived unannounced to deliver complaint findings for the allegations above. LPA met with Caregiver, Charmaine Walters Givans, and explained the reason for the visit. Licensee/Administrator, Rajwant Panesar arrived at 2:08PM.

During the course of the investigation, the Department conducted interviews with staff, residents, witnesses, and the complainant. The Department also reviewed various records related to Resident (R1), including but not limited R1’s pre appraisal agreement, identification and emergency information, admission agreement, physician's report and Needs/Services plan, showering/bathing/changing diapers’ schedules, level of care notes / functional assessments and special incident reports. Additionally, medical records from the hospital were obtained and reviewed. The facility's client roster and staff schedule were also collected and examined.

Continue on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 15-AS-20250808150541
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/05/2026
NARRATIVE
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Continued from LIC9099

Staff did not seek medical attention for resident in a timely manner.

During the Department’s interview on 11/13/2025, W1 stated that on 8/4/2025, W1 went to the facility to drop off supplies. S2 reported to W1 that there was something wrong with R1’s foot. W1 examined R1’s foot and noticed something was wrong with R1’s left leg. R1 was transported to the hospital the same day. On 9/10/2025, the Department obtained a copy of R1’s medical record from 8/4/2025 that indicated R1 received x-rays to R1’s left foot, ankle, knee and hip. Radiology imaging showed a left distal femur fracture. R1’s orthopedic progress notes dated 8/5/2025 indicated “interval healing/callus formation suggesting at least 6+ weeks of healing”. The Department interviewed S1 on 11/26/2025, and S1 denied R1 having any falls while at the facility. S1 stated R1’s legs and knees always looked distorted, because R1 had arthritis. S1 added R1’s legs were never straight and S1 did not see anything abnormal with R1’s legs. According to S1, staff did not report to S1 of any falls. However, S1 believed that the injury occurred when “R1 would get R1’s leg on the side of the bed rail and got twisted the wrong way”.

Staff did not notify resident's responsible party of incident.



Interview with W1 revealed facility did not notify W1 of R1’s leg injury timely, W1 was informed by physician of R1's leg being injured for approximately 6-8 weeks upon admission to the hospital. Interview with S1 revealed, R1's leg was never straight and S1 believed R1’s diagnoses or caused the leg to get worst. Interview with S1 also revealed that S1 did not see a need to notify the R1’s responsible party of R1’s leg being worst. Record review revealed facility did not update R1’s appraisal needs and service plan with the change of condition and provide a copy to R1's responsible party.

Continue on LIC9099C...

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 15-AS-20250808150541
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/06/2026
Section Cited
CCR
87465(g)
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87465(g) Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
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By POC date, Licensee agreed to implement a plan on emergency response protocols, specifically when it is required to immediately contact 9-1-1. Licensee will also provide training to all staff from an authorized vendor regarding emergency response procedures, including specific criteria for contacting 9-1-1. Facility will submit the new plan and in-service date to CCLD.
Immediate $500 Civil Penalty is being assessed.
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This requirement is not met as evidenced by: Based on investigation, licensee did not comply with the section cited above by failing to contact 911 medical attention for R1's left femur fracture injury which posed an immediate health and safety risk to the persons 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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/08/2025 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250808150541

FACILITY NAME:SACRED HANDS LIVINGFACILITY NUMBER:
079201439
ADMINISTRATOR:PANESAR, RAJWANTFACILITY TYPE:
740
ADDRESS:2980 BLUMEN AVETELEPHONE:
(925) 392-8652
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 4DATE:
05/05/2026
UNANNOUNCEDTIME BEGAN:
01:42 PM
MET WITH:Charmaine Walters Givans, CaregiverTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Resident fell resulting in fracture.
Staff left resident soiled for an extended period of time.
INVESTIGATION FINDINGS:
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On 05/05/2026 at 1:42PM, Licensing Program Analysts (LPA), T. Syess-Gibson arrived unannounced to deliver complaint findings for the allegations above. LPA met with Caregiver, Charmaine Walters Givans, and explained the reason for the visit. Licensee/Administrator, Rajwant Panesar arrived at 2:08PM.

During the course of the investigation, the Department conducted interviews with staff, residents, witnesses, and the complainant. The Department also reviewed various records related to Resident (R1), including but not limited R1’s pre appraisal agreement, identification and emergency information, admission agreement, physician's report and Needs/Services plan, showering/bathing/changing diapers’ schedules, level of care notes / functional assessments and special incident reports. Additionally, medical records from the hospital were obtained and reviewed. The facility's client roster and staff schedule were also collected and examined.

Continue on LIC9099C....
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 15-AS-20250808150541
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/05/2026
NARRATIVE
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Continued from LIC9099

Resident fell resulting in fracture.

During an interview with W1 on 11/20/2025, W2 on 08/25/2025, S1 on 11/26/2025, S2 on 11/26/2025, and S3 on 11/21/2025, interviews revealed that R1 has not had any witnessed falls and does not have any knowledge of R1 falling. During Interview with S1 on 11/26/2025, S1 stated she believes the injury occurred when R1 would put her leg on the side of the bed rail and got twisted the wrong way. During record review of R1’s physician's report dated 09/04/2024, it was noted R1 with a diagnosis of dementia. According to R1’s Appraisal Needs and Service Plan, R1 requires assistance with ADLS and is able to pivot from side to side when transferring from bed to wheelchair. R1’s medical record indicates that R1 was admitted to the hospital on 08/04/2025 due to foot pain. R1 was discharged on 08/09/2025, with a diagnosis of a left distal femur fracture and interval healing/callus formation suggested at least six (6+) plus weeks of healing. Medical records does not reveal injury is a result of R1 falling.

Staff left resident soiled for an extended period of time.

Interview with W1 revealed R1 was observed being soiled during a visit in January 2023. Interview with W1 also revealed that W1 has not observed R1 being soiled since the incident in January 2023. Interviews with S1 and S2 revealed staff changes incontinence residents every two hours, between meals, and as needed when staff has observed residents are soiled.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted. A copy of this report and appeal rights provided.

Exit interview conducted and a copy of this report was provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 15-AS-20250808150541
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/05/2026
NARRATIVE
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Continued from LIC9099C



Based on the Department’s investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Health and Safety Code are being cited on the attached LIC809D.

A $500.00 immediate civil penalty is being assessed on this day. Civil penalty determination related to serious bodily injury is pending. A formal conference with CCLD will be scheduled at a later time.

Exit interview conducted. A copy of this report, LIC421IM, and appeal rights were provided to Rajwant Panesar.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 15-AS-20250808150541
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2026
Section Cited
CCR
87211(a)(1)
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(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....
This requirement is not met as evidenced by

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By POC date, Licensee agreed to obtain training for all staff on reporting requirements from an authorized vendor and submit certifications to CCLD.
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 Based on interview, observation, and record review, the licensee did not comply with the section above by not reporting R1’s incidents to CCL and the person responsible for R1 which posed a health, safety and personal rights risk to the persons 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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7