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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320041
Report Date: 09/13/2023
Date Signed: 09/13/2023 12:09:23 PM

Document Has Been Signed on 09/13/2023 12:09 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: 6DATE:
09/13/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator Michelle Porca TIME COMPLETED:
12:45 PM
NARRATIVE
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On 09/13/2023 at 8:00 am, Licensing Program Analyst (LPA) David España conducted an unannounced complaint visit at this facility, LPA was greeted by S4 and later Administrator Michelle Porca. LPA explained the purpose of the visit is to investigate the allegation mentioned above. LPA conducted a risk assessment at the entrance of the facility, and there are no COVID-19 cases at this time. The facility is licensed to operate for six (6) non-ambulatory elderly residents ages 60 and above. The facility is approved for six (6) hospice residents. Currently, there are four (4) hospice residents in care. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident's rooms, one (1) staff room, two (2) common bathrooms, a living area, a dining area, a kitchen, and an outside patio area. LPA and licensee toured the physical plant.

Based on LPA(s) observation and inspection the following resident bathroom(s) to have hot water temperature reading of 96.2 degree F.

Title 22, Division 6 Chapter 8 Article 05. Physical Environments and Accommodations 87303 Maintenance and Operation is being cited on the attached LIC 809D.

Deficiencies

87303(e)(1)(A)(B)(2-6)

A copy of this report and appeal rights was provided and discussed and left with Licensee Administrator Michelle Porca whose signature on this form confirm receipt of these documents.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2023
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 09/13/2023 12:09 PM - It Cannot Be Edited


Created By: David Espana On 09/13/2023 at 10:53 AM
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: 09/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2023
Section Cited
CCR
87303(e)(A)(B)(2-6)

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Faucets used by residents for personal care...grooming shall... Hot water temperature controls...regulate the temperature of hot water...a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F...
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Administrator will have how water temperature reading between 105F and 120F degrees for all facility bathrooms/restrooms by the POC due date. LPA will return to check correction.
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This requirement has not been met as evidenced by: Based on LPA(s) observation and inspection the following resident bathrooms there was hot water temperature reading of 96.2 degree F.
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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.
SUPERVISOR'S NAME:Ulysses Coronel
LICENSING EVALUATOR NAME:David Espana
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023


LIC809 (FAS) - (06/04)
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