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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320041
Report Date: 03/29/2023
Date Signed: 03/29/2023 03:10:42 PM

Document Has Been Signed on 03/29/2023 03:10 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
EL SEGUNDO, 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: 5DATE:
03/29/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:17 PM
MET WITH:Michelle Porca TIME COMPLETED:
03:59 PM
NARRATIVE
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On 03/29/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a case management inspection visit at this facility. LPA met with Admnistrator Michelle Porca and explained the purpose of the visit.

During a complaint investigation visit on 03/29/23 control #11-AS-20230327150607 related to resident #1 (R1), LPA identified former resident #1 (R1) who was admitted at a local hospital on 05/12/22 and was on hospice care was not reported to Community Care Licensing (CCL) in timely manner with a LIC 624. (R1) required a higher level of care with restricted health conditions and did not return to the facility.

The licensee violated Title 22 Regulations 82711- Reporting Requirements and 87632 - Hospice Care Waiver California Code of Regulations (Title 22, Division 6, Chapter 8), deficiencies were observed, and citations were issued (ref. LIC 9099-D).
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/29/2023 03:10 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 03/29/2023 at 12:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
87211(a)(D)

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87211 Reporting Requirements (a) licensee shall furnish to the licensing agency such reports as the Department... (1) A written report shall be submitted to the licensing agency... within seven days..(D) Any or health of any resident.. or unexplained absence of any resident.
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Licensee/Administrator will adhere to the regulations and will ensure any changes in resident's health condition or death will be reported to CCLD. 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 with licensee, Licensee failed to report incident with R1 admitted to hospital for change of health condition. This violation possesses a potential Health and Safety risk to residents in care.
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*Corrected during visit 03/2/9/23*
Type B
04/05/2023
Section Cited
CCR87632(2)

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87632 Hospice Care Waiver (2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services...
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Licensee/Administrator will adhere to Title 22 87632 regulations and will ensure notify CCL of hospice residents in care. 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 with licensee, Licensee failed to notifiy CCL with resident R1 admitted at this facility who was on hospice care. This violation possess a potential Health and Safety risk to residents in care.
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*Corrected during visit 03/2/9/23*
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: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


LIC809 (FAS) - (06/04)
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