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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006528
Report Date: 05/07/2024
Date Signed: 05/07/2024 02:57:08 PM

Document Has Been Signed on 05/07/2024 02:57 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:
05/07/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:23 PM
MET WITH:Licensee Tin LeTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst's (LPA) Jenifer Tirre and Michael Tea made an announced inspection visit to follow up on corrections identified during Pre Licensing visit on 05/3/2024. LPA's identified themselves and discussed the purpose of the visit with Licensee Tin Le. An initial application to operate a Residential Facility Care for the Elderly was submitted to CCL on 3/10/2024. There are 0 residents in care during today's visit. LPA's observed the following:

At 2:00 PM, LPA's toured the facility and observed the following:
  • a secure door knob/lock was observed on staff room
  • Facility has First Aid kit & First Aid Manual
  • Facility has a tablet device with internet for resident use
  • Adequate perishable & non- perishable foods
  • Adequate Emergency food & water supply
  • Facility has Department postings
  • Skid proof mat provided in restroom 1
  • Facility has Fire Extinguisher tagged by Fire department
  • Audible alarms are operational on all sliding doors
  • Facility has call buttons for resident rooms that notify inside kitchen area


Licensee ordered Pub 475 poster in correct size and waiting to receive. Licensee to provide proof of poster upon delivery to LPA.
Licensee confirmed that phone company is scheduled to set up land line phone on 5/8/24. Licensee to provide proof of phone set up with new land line phone number by 5/8/24. Licensee using cell phone number until land line is operable

Noted items from visit on 05/03/2024 have been addressed.


The facility is ready to be licensed.


Exit interview 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: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2024
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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