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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320041
Report Date: 01/04/2022
Date Signed: 01/04/2022 03:46:48 PM

Document Has Been Signed on 01/04/2022 03:46 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:GOOD HANDS HOMECAREFACILITY NUMBER:
198320041
ADMINISTRATOR:PORCA, MICHELLE ANNFACILITY TYPE:
740
ADDRESS:105 W. 225TH STREETTELEPHONE:
(310) 422-0950
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 6CENSUS: DATE:
01/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Michelle Ann PorcaTIME COMPLETED:
04:02 PM
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On 1/04/22, Licensing Program Analysts (LPA) Gail Johnson and Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA Johnson met with the licensee/administrator Michelle Ann Porca. LPA Johnson explained the purpose of today’s visit. The facility is licensed to operate for (6) non-ambulatory clients (60 and older). This facility is licensed as a Residential Care For the Elderly and to service clients with dementia.

The facility is a one-story structure located in a residential neighborhood. It consists of the following: four (4) bedrooms (one staff bedroom and four client bedrooms) two bathrooms, living area, dining area, kitchen, and outside patio area. LPA Johnson and LPA Dabuet toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 106.9 F.

Storage areas for personal hygiene, cleaning supplies, toxins, and sharp objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. Three fire extinguishers were charged, smoke detectors and carbon monoxide were operable.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Gail Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2022
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GOOD HANDS HOMECARE
FACILITY NUMBER: 198320041
VISIT DATE: 01/04/2022
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During the visit, LPA Johnson and LPA Dabuet observed the facility's infection control practices. LPA Johnson observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA Johnson observed staff was wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection 'control posters were posted. There was appropriate signage throughout the facility (encouraging physical distancing on the floors). Staff and resident temperature logs were reviewed. The facility has a Mitigation Plan Report approved by CCLD on file.



An exit interview was conducted with Michelle Ann Porca. A copy of this report was printed and provided to Michelle Ann Porca.

An LIC-9102 is provided for technical assistance.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Gail Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022
LIC809 (FAS) - (06/04)
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