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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006528
Report Date: 05/03/2024
Date Signed: 05/03/2024 04:15:46 PM

Document Has Been Signed on 05/03/2024 04:15 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 HOME CAREFACILITY NUMBER:
306006528
ADMINISTRATOR/
DIRECTOR:		LE, TINFACILITY TYPE:
740
ADDRESS:16242 BRIMHALL LANETELEPHONE:
(714) 600-7083
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY: 6CENSUS: 0DATE:
05/03/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:01 PM
MET WITH:Licensee Tin LeTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst's (LPA's) Jenifer Tirre and Michael Tea visited this facility for the purpose of conducting a Pre-Licensing evaluation for change of location. Facility is a single story residential home. LPA's along with Licensee/Administrator Tin Le toured facility at 2:10 PM and observed the following:

Fire clearance approval was received on 03/14/24. Structure: Facility is a one story, 4 bedroom (3 Residents bedrooms and 1 live in staff bedroom) 2 bathroom house with attached garage and a white exterior. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: All Residents bedrooms need additional furnishings such as beds. Bathrooms: All resident bathrooms have a working toilet, wash basin, and bathtub/shower as well as grab bars. One of two restrooms has a non-skid surface in the shower. Linens & Hygiene Supplies: Facility has adequate supply of linens and towels. Emergency Phone Numbers and Exit Plan: Facility has Emergency Plan. Food Service: Facility does not have 2 day perishables & 7 day non-perishables in the pantry/ refrigerator, as well as emergency food and water supply. Smoke Detectors: Smoke detectors/ carbon monoxide detector are centrally wired and were tested operational. Facility has one fire extinguisher which is mounted and charged. Facility has audible alarms on entry/exit doors. Appliances: Gas Stove and refrigerator are operational. Toxins: LPA observed toxins secured in storage area.. Water Temperature: Tested and recorded at 106.7 degrees F. in facility bathrooms. Reading Material Games, and Equipment:

facility did not have activity supplies at time of visit. Medications, First-Aid Kit & Book: Facility did not have first aid kit or First aid manual present at the facility. Facility has a secured location for medications and facility files. Backyard: LPA observed the facility perimeter is secured by wall with a self latching gate on right side of facility as required. LPA observed shaded outdoor seating.

Component III Orientation was waived during this pre-licensing visit due to Administrator presently operating several facilities.


CONTINUED ON 9099C
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 HOME CARE
FACILITY NUMBER: 306006528
VISIT DATE: 05/03/2024
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Licensee to address the following corrections by 5/6//2024:
  • Facility to provide a secure door knob/lock on staff room
  • Facility to provide First Aid kit & First Aid Manual
  • Facility to provide a tablet device with internet for resident use
  • Facility to provide Adequate perishable & non- perishable foods
  • Facility to provide Emergency food & water supply
  • Facility to provide Department postings
  • Facility to provide skid proof mat for restroom 1
  • Facility to provide a updated Fire Extinguisher tagged by Fire department
  • Facility to provide audible alarms on all sliding doors
  • Facility to provide a land line phone on premise
  • Facility to provide call buttons for room


The facility is not ready to be licensed. Licensee to contact LPA when corrections are complete.
An exit interview was conducted with Licensee and a copy of this report was left at the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC809 (FAS) - (06/04)
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