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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005623
Report Date: 07/11/2022
Date Signed: 07/11/2022 01:56:52 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/05/2022 and conducted by Evaluator Rosie Quiroz
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220705140623
FACILITY NAME:GOOD HANDS HOME CAREFACILITY NUMBER:
306005623
ADMINISTRATOR:LE, TINFACILITY TYPE:
740
ADDRESS:18674 SAN FELIPE STREETTELEPHONE:
(714) 600-7083
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 5DATE:
07/11/2022
UNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Tin Le, AdministratorTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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-Facility staff and other adults who are not clients living at the facility do not have a criminal background clearance.
INVESTIGATION FINDINGS:
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 This unannounced visit conducted by Licensing Program Analyst (LPA) Rosie Quiroz is being conducted to initiate the 10 day visit to investigate the above mentioned complaint allegation. LPA Quiroz arrived at the facility was greeted and granted entry by Staff 4 (S4). Administrator (AD) Tine Le arrived shortly after and was explained the nature of today's visit.

During the course of the investigation, interviews conducted with interviewees, a tour of the physical plant was completed, a review of resident and staff records were completed. LPA Quiroz requested the following documents and were obtained on today's date: Current LIC 500 Personnel Report, Physician report and Identification forms for Resident 1, Resident 2, Resident 3, Resident 4 and Resident 5.

CONTINUED ON NEXT PAGE...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
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 3
Control Number 22-AS-20220705140623
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 HOME CARE
FACILITY NUMBER: 306005623
VISIT DATE: 07/11/2022
NARRATIVE
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During today's visit, LPA Quiroz reviewed the criminal background clearance of Staff (S1), Staff 2 (S2), Staff 3 (S3) and Staff 4 (4) present during today's visit. Based on file review and interviews conducyed, LPA Quiroz did not find any proof of criminal background clearance for (S4). LPA Quiroz immediately provided consultation on background clearance and requested for (S4) to immediately leave the facility. LPA Quiroz observed (S4) leaving the facility immediately thereafter.

Based on the preponderance of evidence gathered through multiple interviews, observations and documents obtained on today's date; the allegation “Facility staff and other adults who are not clients living at the facility do not have a criminal background clearance" is deemed to be SUBSTANTIATED.

For this visit, deficiency was observed for 87355(a) Caregiver Background Clearance. Citation was issued per Title 22 Division 6 of the California Code of Regulations. Civil penalty assessed during today's visit.

An exit interview was conducted with AD Tin Le, and a copy of this report, along with LIC9099-D, Appeal Rights, LIC 811's (identifying confidential names), Civil penalty assessment caregiver background check LIC 421BG, were provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20220705140623
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 HOME CARE
FACILITY NUMBER: 306005623
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/11/2022
Section Cited
CCR
87355(a)
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87355(a) Criminal Record Clearance. (a) The Department shall conduct a criminal record review of all individuals... and shall have the authority to approve or deny... presence in the facility, based upon the results of such review. This requirement was not met as evidenced by:
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LPA Quiroz requested Staff 4 to leave premises immediately. AD Tin Le requested for Staff 1 with background clearance who was present but off on today's date to relieve Staff 4.
Immediate risks reduced.
Immediate civil penalty was assessed.
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Based on file review and interview, the Facility did no secure criminal background clearance for Staff4 (S4). S4 was allowed to reside in facility and have direct contact with the residents without criminal background clearance since 7/10/2022. This poses immediate threat to safety of the residents in care.
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LPA provided copy of the cited regulations for full reference. AD Tine Le aware S4 required background clearance and association prior to working or residing at facility.
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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: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3