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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320041
Report Date: 03/29/2023
Date Signed: 03/29/2023 03:00:53 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/27/2023 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230327150607
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: 5DATE:
03/29/2023
UNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Michelle Porca TIME COMPLETED:
02:59 PM
ALLEGATION(S):
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Staff did not provide records to resident's authorized representative in a timely manner.
INVESTIGATION FINDINGS:
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On 03/29/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint visit at this facility, LPA was greeted by administrator Michelle Porca. LPA explained the purpose of the visit is to investigate the allegation mentioned above.

INVESTIGATION REVEALED THE FOLLOWING: The complainant requested an investigation concerning resident #1 (R1) who formerly resided at this facility. According to the complainant, the facility failed to provide the service records requested to (R1's) representatives. These records were requested on 02/15/23 from the facility. According to the complainant, several email communications and phone calls were made to Good Hands HomeCare legal representative on the following dates: 03/09/23, 03/10/23, 03/23/23 and 03/28/23 with no response.

Evaluation Report continues LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
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 11-AS-20230327150607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GOOD HANDS HOMECARE
FACILITY NUMBER: 198320041
VISIT DATE: 03/29/2023
NARRATIVE
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The Department interviewed administrator Michell Porca staff #1 (S1) who recalled receiving a Medical Record request in 02/22/23 and forwarded the request immediately to the facility’s legal representative on 02/24/23. (S1) claimed once it was forwarded to their legal representative, (S1) was no longer involved with any communications with any of the parties once it was handled by legal representatives.

An interview with the legal representative witness #1 (W1) verified responding to the request in late February 2023. (W1) requested additional supporting legal documents including a Declaration of Custodian of Records for (R1). The completed documents were received on 03/13/23 according to (W1). (W1) last email communication with the complainant was on 03/16/23 in a statement “working on it”. According to (W1) there have been no follow-up calls or email communications to the complainant regarding the service records and when they will be provided to the complainant. The complainant reported there has been limited update on the request and that the legal representative (W1) failed to provide the day, time, or date when medical records will be available. There is no evidence of (W1) was in communication with the complainant for 13 days since 03/16/23 to explain the reason for the delays.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; the facility failed to make available upon written consent Title 22 section § 87506(c)(1). Therefore, the allegation of: “Staff did not provide records to resident's authorized representative in a timely manner” is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Health and Safety Code), the following deficiency has been observed and a citation issued (ref. LIC 9099-D).

An exit interview was conducted with Michelle Porca, and a copy of the report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20230327150607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOOD HANDS HOMECARE
FACILITY NUMBER: 198320041
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/05/2023
Section Cited
CCR
87506(c)(1)
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87506-Resident Records (c) All information and records obtained from or regarding residents shall be confidential. … (1) The licensee shall be responsible for storing active and inactive records...licensee… shall reveal or make available confidential information… upon the resident's written consent or… designated representative.
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Licensee/Administrator will adhere to the regulations and review Title 22 87506 and will ensure to release resident records upon written request on timely manner. Licensee will ensure to provide proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 04/05/23.
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This requirement is not met as evidence by:
Based on interview, Licensee did not make (R1) service records available on time upon written request. This violation possesses a potential Health and Safety risk to residents in care.
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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: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3