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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005219
Report Date: 11/26/2024
Date Signed: 11/26/2024 05:07:26 PM

Document Has Been Signed on 11/26/2024 05:07 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GOOD HANDS LOVING CARE-YORBA LINDAFACILITY NUMBER:
306005219
ADMINISTRATOR/
DIRECTOR:		YOO, DANIELFACILITY TYPE:
740
ADDRESS:18568 ARBOR GATE LNTELEPHONE:
(949) 878-0137
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 6CENSUS: 4DATE:
11/26/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:31 PM
MET WITH:Daniel Yoo, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted a case management visit to document deficiencies observed during the investigation of complaint 22-AS-20241118163642 but unrelated to the allegations investigated.

During a tour of the physical plant and subsequent review of resident records, LPA observed that all four residents were non-ambulatory and that all four were admitted onto hospice and currently receiving hospice care. However, based on the terms of its license, the facility has a fire clearance for three ambulatory and three non-ambulatory residents along with a hospice waiver for three residents. Licensee is therefore in violation of the terms of its license along with its hospice waiver.

Two type A citations are issued during the present visit. 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
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 11/26/2024 05:07 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 11/26/2024 at 04:18 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
, 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
87705(c)(1)

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Per CCR 87705(c)(1): (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (1) The facility has a nonambulatory fire clearance for each room that will be used to accommodate a resident with dementia(...)" This requirement is not
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Licensee to immediately request an update of its current fire clearance to extend to six non-ambulatory.
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met as evidenced by: Based on observation and records reviewed, all four current resident are non-ambulatory even though the facility is only cleared for 3 ambulatory and 3 non-ambulatory. This constitutes an immediate risk to the health, safety and personal rights of residents in care.
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Type A
11/27/2024
Section Cited
CCR87632(a)(1)

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Per CCR 87632(a)(1): " In order to (...) retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. [which include] Specification of the maximum number of terminally ill [residents]". This
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Licensee to immediately communicate their plan to return to compliance either by limiting the number of hospice residents admitted or by submitting an update request for a hospice waiver with sufficient capacity.
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requirement is not met as evidenced by: Based on records reviewed and facility visit, there are four residents currently receiving hospice care even though the facility's waiver is only for three residents. This consitutes an immediate risk to the health, safety and personal rights of individuals 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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