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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005219
Report Date: 11/26/2024
Date Signed: 11/26/2024 05:09:50 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/18/2024 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20241118163642
FACILITY NAME:GOOD HANDS LOVING CARE-YORBA LINDAFACILITY NUMBER:
306005219
ADMINISTRATOR:YOO, DANIELFACILITY TYPE:
740
ADDRESS:18568 ARBOR GATE LNTELEPHONE:
(949) 878-0137
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:6CENSUS: 4DATE:
11/26/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Daniel Yoo, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
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5
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8
9
Facility retained a resident with a prohibited health condition

Facility did not submit a written exception request for resident with a prohibited health condition

Facility used postural supports to limit the use of a resident's hands and feet
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the initial investigation into the four allegations listed above. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the visit. Administrator Daniel Yoo was notified of the visit via telephone and arrived later to assist.

During the visit, LPA accompanied by faclity staff toured the facility's physical plant. There are currently four residents in care. Resident records for all four currently admitted individuals along with two recent discharges were requested and reviewed. Staff training records were also requested and reviewed during the visit.

CONTINUED ON FORM LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
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 6
Control Number 22-AS-20241118163642
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/26/2024
NARRATIVE
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CONTINUED FROM FORM LIC9099
Regarding the allegation that Facility retained a resident with a prohibited health condition, the following has been concluded: Resident R1 is no longer admitted to the facility on the day of the visit and is stated to have been discharged on November 18, 2024. However based on staff interviews conducted along with a review of the resident's records maintained at the facility including the admission agreement, individual facesheet and individual needs and services assessment, R1 has lived at the facility from January 12, 2024 until their discharge in November of the same year. Records reviewed including the resident's physician report clearly indicate that the resident had a gastrostomy tube present upon their admission until their discharge. Based on staff statement, R1 was receiving home health services but was not on hospice during their period of admission. The allegation is therefore Substantiated, meaning that the preponderance of evidence threshold has been met.

Regarding the allegation that Facility did not submit a written exception request for resident with a prohibited health condition, the following has been concluded: Facility staff confirms that no request for an exception was submitted. Identically, R1 was never admitted onto hospice and only had home health during their admission. The allegation is therefore Substantiated, meaning that the preponderance of evidence threshold has been met.

Regarding the allegation that Facility used postural supports to limit the use of a resident's hands and feet, the following has been concluded: Based on interviews and records reviewed, resident R1 had an order for postural support via half-length bed rails to be provided. Resident was not admitted onto hospice care during the period of admission at the facility. However, based on evidence provided during the investigation, facility staff eventually installed full-length bed rails in spite of the orders and hospice status of the resident. Additionally, the bed sheets were observed to have been tied to the rails, further impeding on the ability of the resident to reposition themselves as needed. As a result, the allegation is also Substantiated, meaning that the preponderance of evidence threshold has been met.

Three type A citations are issued to the facility on attached form LIC9099-D. An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/18/2024 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20241118163642

FACILITY NAME:GOOD HANDS LOVING CARE-YORBA LINDAFACILITY NUMBER:
306005219
ADMINISTRATOR:YOO, DANIELFACILITY TYPE:
740
ADDRESS:18568 ARBOR GATE LNTELEPHONE:
(949) 878-0137
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:6CENSUS: 4DATE:
11/26/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Daniel Yoo, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff are not properly trained
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the initial investigation into the four allegations listed above. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the visit. Administrator Daniel Yoo was notified of the visit via telephone and arrived later to assist.

During the visit, LPA accompanied by faclity staff toured the facility's physical plant. There are currently four residents in care. Resident records for all four currently admitted individuals along with two recent discharges were requested and reviewed. Staff training records were also requested and reviewed during the visit.

CONTINUED ON FORM LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 22-AS-20241118163642
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/26/2024
NARRATIVE
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CONTINUED FROM FORM LIC9099-A
Regarding the allegation that Facility staff are not properly trained, the following has been concluded: During the facility visit, LPA reviewed staff files for three care staff members, including but not limited to their current training transcripts which meet the requirements for the duration of initial and annual training along with the variety of topics covered which include postural supports, medication administration and dementia management. Regarding the management of R1's g-tube feeding, one staff member is verified to have current licensure as an LVN. Interviews conducted corroborated the fact that the staff member in question provided training to other care staff.

As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation occurred.

An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 22-AS-20241118163642
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/27/2024
Section Cited
CCR
87615(a)(2)
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Per CCR87615(a)(2): "Persons who require health services for or have a health condition including (,...) those specified below shall not be admitted or retained in a residential care facility for the elderly: (2) Gastrostomy tubes". This requirement is not met as evidenced by:
1
2
3
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5
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7
Licensee to review applicable regulations to Prohibited Health Conditions and update training to all staff members accordingly. Proof of training to be provided to LPA.
R1 is no longer admitted to the facility.
8
9
10
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14
Based on staff statements and records reviewed, resident R1 was admitted and stayed at the facility while being treated from dysphagia with a G-tube. This deficiency constitutes an immediate risk to the health, safety and personal rights of residents in care.
8
9
10
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Type A
11/27/2024
Section Cited
CCR
87616(a)
1
2
3
4
5
6
7
Per CCR 87616(a) "As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited (...) health condition but believes that the intent of the law can be met through alternative means". This requirement is not met as (...)
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Resident R1 was discharged at the time of the visit. Deficiency cleared.
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evidenced by: Licensee did not submit and/or obtain a written exception request prior to admitting resident R1.
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9
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14
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: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 22-AS-20241118163642
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/27/2024
Section Cited
CCR
87608(a)(5)(B)
1
2
3
4
5
6
7
Per CCR 87608(a)(5)(B): "Under no circumstances shall postural supports include (...) limiting the use of a resident's hands or feet. (...)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care". This requirement is not met as evidenced
1
2
3
4
5
6
7
Licensee to update training on postural supports for all staff. Documentation of training to be provided to LPA.
8
9
10
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14
by: Based on evidence submitted and records reviewed, it was determined that R1's bed had been equipped with full rails in the absence of hospice placement and appropriate physician orders. This constitutes an immediate risk to the health, safety and personal rights of residents in care
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7
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7
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5
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7
1
2
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5
6
7
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: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6