306005219-7-3-2024-22-AS-EKIM-D6TQMW-20240703121812

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005219
Report Date: 07/03/2024
Date Signed: 07/03/2024 12:18:27 PM

Document Has Been Signed on 07/03/2024 12:18 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	GOOD HANDS LOVING CARE-YORBA LINDA		FACILITY NUMBER:	306005219
ADMINISTRATOR:	YOO, DANIEL		FACILITY TYPE:	740
ADDRESS:	18568 ARBOR GATE LN		TELEPHONE:	(949) 878-0137
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	6	CENSUS: 6	DATE:	07/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Daniel Yoo		TIME COMPLETED:	12:40 PM

NARRATIVE

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On July 3, 2024, at 8:00am, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Administrator (AD) Daniel Yoo and explained the purpose of the visit.

The facility is licensed to operate for three (3) ambulatory and three (3) non-ambulatory of which three may be bedridden and have a hospice waiver for three (3) residents. The facility is a two story structure located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, living room, dining room, kitchen, swimming pool, jacuzzi, koi pond, attached 2-car garage, staff break area on the second floor, and an outside covered patio area.

LPA Kim toured indoor and outdoor of the physical plant with AD Yoo. There are no obstructions on the premises. There is a swimming pool, jacuzzi, and a koi pond in the backyard that is surrounded by a fence with two entrances with each entrance having a self-closing latch and opening away from the swimming pool, jacuzzi, and koi pond. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, and Staff Room 1. The second floor is used for storage and a break area for the staff. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 117.6 degrees F.

LPA Kim 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 a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly.

Evaluation Report Continues on LIC 809-C.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GOOD HANDS LOVING CARE-YORBA LINDA	FACILITY NUMBER: 306005219
	VISIT DATE: 07/03/2024

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During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). The facility conducts Fire/Safety Drill quarterly and was last conducted on April 23, 2024. Emergency food, water, and supplies are stored in the garage. A working telephone (714-340-3315) remains available. The facility has two (2) fire extinguisher that are charged and mounted in the kitchen and on the second floor. All smoke/carbon monoxide detectors were operable. A comfortable temperature of 77 degrees F was maintained in the facility.

LPA conducted an audit of resident files (R1-R6), staff files (S1-S4) and medication and medication administration review. LPA Kim conducted 4 staff interviews.

A technical violation was assessed during this inspection visit according to the California Code of Regulations (Title 22, Division 6, Chapter 8).

A Deficiency was cited during this inspection visit according to the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted and a copy of this report along with the appeal rights (LIC 9058) were provided to Administrator Daniel Yoo

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/03/2024 12:18 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
ORANGE COUNTY RO, 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: 07/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above. LPA observed R1, R2, R3, and R4 are diagnosed with Dementia and did not have their current medical assessment. R1, R2, and R3 did not have a current Appraisal Needs and service plan. R6 did not have a medical assessment at the time of visit. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/19/2024
	Plan of Correction
1 2 3 4	Licensee states they will provide a current Physican's Report for R1, R2, R3, R4, and R6, and a current Appraisal Needs and Service Plan for R1, R2, and R3 with proof of corrected POC to CCLD via email to edward.kim@dss.ca.gov by July 19, 2024.

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: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024

LIC809 (FAS) - (06/04)

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