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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005623
Report Date: 08/08/2022
Date Signed: 08/08/2022 01:28:57 PM


Document Has Been Signed on 08/08/2022 01:28 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 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:
08/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Tin Le, Licensee AdministratorTIME COMPLETED:
01:30 PM
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 On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA Quiroz was greeted and granted entry into the facility by Caregiver 1 (CG1). Licensee/Administrator (L/AD) Tin Le arrived shortly after, and explained the reason for the visit. This facility is licensed to provide services to residents age 60 and over, 6 Non Ambulatory Residents, and has a hospice waiver for 4 residents. Administrator Tin Le has an active Administrator Certificate with expiration date of 11/28/2022.
At 12:45PM, LPA Quiroz along with (L/AD) Tin Le toured the inside and outside of facility. The Facility has currently 5 residents in care during today's visit. LPA Quiroz observed three of five residents in living-room area relaxing supervised by caregiver 2. LPA Quiroz observed two of five residents in their bedrooms resting. Five of five residents present in the facility appeared happy and well taken care of. Facility appears clean and sanitary. All resident rooms had the required elements as well as restrooms stocked with soap/ sanitizer and paper towels. The first floor includes, kitchen, dining-room, office staff, laundry room, garage, 3 shared bedrooms and 2 bathrooms for residents and visitors. The second floor includes 3 bedrooms and 1 bathroom and is utilized for live in caregivers and Administrator headquarters.
The Facility screens all visitors to the facility. LPA Quiroz observed the screening/ sanitizing station in the facility upon entrance. The Facility utilizes a visitor sign in sheet. Facility takes resident temperatures and documents results daily. LPA Quiroz observed ample sanitizer spread out throughout the facility. LPA Quiroz toured the outside grounds and observed the shaded outside visitation area. Exit gates are unlocked. LPA Quiroz observed the locked medication storage area. Facility has a plan for COVID-19 testing residents and staff as needed as well as a plan for isolation and quarantine. LPA Quiroz reviewed five of five resident files during the visit. 5 of 5 residents and all staff are vaccinated for COVID-19 and have received two boosters.
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SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2022
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GOOD HANDS HOME CARE
FACILITY NUMBER: 306005623
VISIT DATE: 08/08/2022
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During today's visit LPA Quiroz consulted with Administrator Le and caregiver present regarding the importance of continuing to follow department recommended guidelines for COVID-19 precautions and visitation for residents.

During today's visit, no deficiencies were observed and the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with (L/AD) Tin Le, and a copy of this report and LIC 811-Confidential names list were provided at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
LIC809 (FAS) - (06/04)
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