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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005219
Report Date: 01/30/2024
Date Signed: 01/30/2024 12:06:39 PM


Document Has Been Signed on 01/30/2024 12:06 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:GOOD HANDS LOVING CARE-YORBA LINDAFACILITY NUMBER:
306005219
ADMINISTRATOR:YOO, DANIELFACILITY TYPE:
740
ADDRESS:18568 ARBOR GATE LNTELEPHONE:
(949) 878-0137
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:6CENSUS: 4DATE:
01/30/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Daniel Yoo - AdministratorTIME COMPLETED:
12:15 PM
NARRATIVE
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During the investigation into complaint control number 22-AS-20231030161210 it was discovered the facility failed to report a COVID outbreak to the Regional Office.

All serious incidents and outbreaks should be reported to the Regional Office within 7 days, outbreaks should be reported in 24 hours. Good Hands Loving Care-Yorba Linda failed to report that residents tested positive for COVID. The first resident tested positive for COVID October 4, 2023, and families of other residents in the home were notified a resident recently tested positive for COVID.

During the visit, Licensee/Administrator Daniel Yoo confirmed he did not report the COVID cases to the Regional Office.

As a result of today’s Case Management visit, a deficiency will be cited.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
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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Document Has Been Signed on 01/30/2024 12:06 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: GOOD HANDS LOVING CARE-YORBA LINDA
FACILITY NUMBER: 306005219

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/02/2024
Section Cited
CCR
87211(a)(2)

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(a) Each licensee shall furnish...reports as the Department may require, including, but not limited to...
(2) Occurrences, such as epidemic outbreaks... which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours… to the local health officer when appropriate.
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Licensee/Administrator Daniel Yoo will review regulation section 87211 Reporting Requirements and sign a statement of acknowledgement and understanding of the Reporting Requirements.
Licensee/Administrator Daniel Yoo will send a detailed plan that outlines the steps that will be taken to ensure all serious incidents and outbreaks are reported. The detailed plan will include the following:
• Who will be responsible for sending incident reports
• A backup staff member responsible for reporting serious incident reports if Licensee/Administrator Daniel Yoo is unavailable.
The Plan of Correction will be emailed to LPA Haley by Friday, February 2, 2024 at 1PM.
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This requirement is not being met as evidenced by the facility failing to properly report to the Regional Office a COVID outbreak that started October 4, 2023. This poses a potential health and safety risk to 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: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
LIC809 (FAS) - (06/04)
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