198320041-1-12-2024-11-AS-EDAT-CZESNC-20240112130120

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320041
Report Date: 01/12/2024
Date Signed: 01/12/2024 01:01:42 PM

Document Has Been Signed on 01/12/2024 01:01 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	GOOD HANDS HOMECARE		FACILITY NUMBER:	198320041
ADMINISTRATOR:	PORCA, MICHELLE ANN		FACILITY TYPE:	740
ADDRESS:	105 W. 225TH STREET		TELEPHONE:	(310) 422-0950
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY:	6	CENSUS: 6	DATE:	01/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:02 AM
MET WITH:	Michelle Porca		TIME COMPLETED:	12:44 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 01/12/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator and licensee Michelle Porca and explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory elderly residents ages 60 and above. The facility is approved for six (6) hospice residents. Currently, there are four (4) hospice residents in care. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident's rooms, one (1) staff room, two (2) common bathrooms, a living area, a dining area, a kitchen, and an outside patio area. LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 109.6 degrees F. A comfortable temperature of 72 degrees F. was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility has two (2) fire extinguishers that were charged, smoke detectors, and carbon monoxide was operable. LPA reviewed Medication Administration Records (MAR) revealed accurate and maintained in order. The facility conducted a Fire/Safety Drill on 12/02/23. A working landline telephone remains available. The facility has a current liability insurance on file effective 06/23/23 – 06/23/24. Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GOOD HANDS HOMECARE	FACILITY NUMBER: 198320041
	VISIT DATE: 01/12/2024

NARRATIVE

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During the visit, LPA observed the facility's infection control practices. LPA observed staff followed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). Posters mandated for inspection control were posted.

An audit of residents #1-#6 service records and staff #1-#6 personnel records revealed to be completed. Interviews conducted with (1) resident. The facility is current on CCL annual dues. The facility has has a current CCL Administrator Certificate: #6031326735 Expiration - 03/25/25 for Michelle Porca.

LPA observed staff #5 (S5) during file review had Criminal Clearance Background, but did not have a Criminal Clearance Transfer on file and (S5) did not appear on CCLD Guardian portal.

Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8.

Deficiency is issued and an exit interview is conducted with Michelle Porca. A copy of this report, appeal rights was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/12/2024 01:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GOOD HANDS HOMECARE	FACILITY NUMBER: 198320041
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(2)

87355 Criminal Record Clearance - (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on audit review of records, the licensee did not comply with the section. LPA identified staff #5 did not have a Criminal Clearance Background Clearance Transfer associated at this facility. This violation poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/13/2024
	Plan of Correction
1 2 3 4	Licensee to ensure that all staff prior to working in the facility obtain a Criminal Background Clearance and Criminal Background Transfer Request and provide proof of correction to CCLD by POC due date. Proof of Correction due date: 01/13/24. - Corrected during visit with LIC 9182 provided to LPA.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024

LIC809 (FAS) - (06/04)

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