306005695-10-18-2022-22-AS-ETAA-CKBTH3-20221018144406

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005695
Report Date: 10/18/2022
Date Signed: 10/18/2022 02:44:15 PM

Document Has Been Signed on 10/18/2022 02:44 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-FRANCISCO		FACILITY NUMBER:	306005695
ADMINISTRATOR:	YOO, DANIEL		FACILITY TYPE:	740
ADDRESS:	21063 VIA FRANCISCO		TELEPHONE:	(949) 878-0137
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92887
CAPACITY:	6	CENSUS: 5	DATE:	10/18/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:27 PM
MET WITH:	Daniel Yoo		TIME COMPLETED:	03:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection in this facility. LPA met with Administrator Daniel Yoo and stated the purpose of this visit.

The facility is a two-level structure and licensed for four ambulatory and two non-ambulatory. Hospice waiver for three. This facility is a Residential Care Facility for the Elderly.

At about 01:30 pm, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed residents in care and staff members on duty. LPA toured the interior and exterior portions of the facility. There were 3 resident rooms 2 of which were shared rooms. One room was for the Administrator and the second floor was for staff only made inaccessible to residents in care. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair and provided with grab bars and hot water was measured at 115.3 degrees Fahrenheit. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed. Laundry room was equipped with an operational washer and dryer which leads to the garage. Facility offers a 3-car garage which is kept locked and used for storage, emergency food, a refrigerator, and a car. Kitchen was in good repair with cleaning supplies and sharp items inaccessible to residents in care. LPA noticed unlocked medication in the refrigerator. Administrator removed medication immediately and was made aware of citation.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022

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 LOVING CARE-FRANCISCO	FACILITY NUMBER: 306005695
	VISIT DATE: 10/18/2022

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For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. Backyard contained a swimming pool with a locked gate surrounding the pool. The backyard contained trees surrounding the facility.

LPA Tapia reviewed the COVID 19 mitigation plan and the Emergency disaster plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, One deficiency was noted in areas observed.

LPA Tapia conducted an exit interview with Administrator Daniel Yoo and copy of this report with appeal rights were explained and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/18/2022 02:44 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-FRANCISCO	FACILITY NUMBER: 306005695
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

This requirement is not met as evidenced by: The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 1. Medications were observed to be unlocked in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/19/2022
	Plan of Correction
1 2 3 4	Administrator will purchase a lock for the mini refrigerator or will purchase a new mini refrigerator with lock.

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: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022

LIC809 (FAS) - (06/04)

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