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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006528
Report Date: 05/23/2025
Date Signed: 05/23/2025 05:23:16 PM

Document Has Been Signed on 05/23/2025 05:23 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: 5DATE:
05/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Hendrelyn BautistaTIME VISIT/
INSPECTION COMPLETED:
05:36 PM
NARRATIVE
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On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 6 residents and the home currently has 5 residents, with 1 resident on hospice. Staff provided liability insurance that expires on 10/19/2025.

LPA along with staff member 2 (S2) toured the facility at 8:35 AM. LPA toured the physical plant, checked food service and facility documentation. The home consists of 3 resident bedrooms, living room, dining room, kitchen, two staff rooms with one built into the garage, as well as 2 bathrooms. LPA toured the kitchen and observed sharps locked in a cabinet during today's visit. At 8:40 AM, LPA observed a kitchen cabinet with a broken lock containing medication. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. LPA observed the emergency food. At 8:58 AM, LPA observed there is no emergency water at the facility. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. At 9:09 AM, LPA observed unlocked bathroom cabinet with cleaners such as Comet bleach powder and Clorox wipes inside bathroom in bedroom 3. Water temperature measured between degrees 114.4 F and 114.9 in all bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit . Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. Continued on LIC809-C dated 5/23/2025.
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Fred Arias
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 11
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 11
Document Has Been Signed on 05/23/2025 05:23 PM - It Cannot Be Edited


Created By: Fred Arias On 05/23/2025 at 03:55 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 HOME CARE
FACILITY NUMBER: 306006528

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
(a) Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and record review, the staff room construction in the garage did not have evidence of a permit which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/24/2025
Plan of Correction
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Licensee to provide building permit for staff room construction in the garage to LPA by POC due date.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, cleaning supplies were found under the bathroom sink unlocked in bedroom 3 and in the unlocked closet by the entrance which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/24/2025
Plan of Correction
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Cleaning supplies from bathroom were removed and a lock was placed on the closet door during the visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Fred Arias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2025


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 05/23/2025 05:23 PM - It Cannot Be Edited


Created By: Fred Arias On 05/23/2025 at 03:55 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 HOME CARE
FACILITY NUMBER: 306006528

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, lock in lower medicine cabinet is broken making medications available to residents which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/24/2025
Plan of Correction
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Facility to repair/replace lock. LPA to return and verify.
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and record review, R2 has full bed rails. R2 is not on hospice which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/24/2025
Plan of Correction
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Facility to remove full bed rails from R2's bed. LPA to return and verify.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Fred Arias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2025


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 05/23/2025 05:23 PM - It Cannot Be Edited


Created By: Fred Arias On 05/23/2025 at 03:55 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 HOME CARE
FACILITY NUMBER: 306006528

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on LPA observation, record review, and interviews, the facility has not conducted emergency drills in the last 12 months which poses a potential health and safety risk to persons in care.
POC Due Date: 06/06/2025
Plan of Correction
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Facility to perform verifiable disaster drills and provide proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Fred Arias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2025


LIC809 (FAS) - (06/04)
Page: 9 of 11
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: 05/23/2025
NARRATIVE
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LPA observed a staff room built into the garage. This room does not appear in the approved facility sketch and was built after licensure without informing the Department. At 9:30 AM, LPA observed closet by the main entrance is unlocked, containing cleaning supplies.

Outside grounds were toured. Walkways around the home were clear of hazards. First aid kit contained all required items including tweezers, scissors and thermometer. There is shaded outdoor seating for residents. Exit gate is unlocked and operational. LPA reviewed five resident files and three staff files. Resident files did not contain all the required documentation. Resident 1 (R1) did not have a signed Personal Rights form on file. Personal Rights documents for resident 2 (R2), resident 3 (R3), resident 4 (R4), and resident 5 (R5) were not fully completed. R2's file did not contain bed rail orders. LPA observed R2's bed with full bed rails. Staff files reviewed did not contain required documentation as it was revealed through LPA's record review and interviews that training files for Staff 1 (S1), S2, and staff 3 (S3) are falsified . LPA reviewed medication storage and administration. Medications are stored in a kitchen cabinet. Based on LPA observation and record review, medications are not being administered per physician order for R1, R3, and R5. During today's inspection, it was revealed the Administrator is out of the country and there is no designated backup Administrator available. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. Based on LPA record review and interviews, no disaster drills are conducted at the facility.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Fred Arias
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 05/23/2025 05:23 PM - It Cannot Be Edited


Created By: Fred Arias On 05/23/2025 at 03:55 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 HOME CARE
FACILITY NUMBER: 306006528

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(c)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review and interviews, required new hire staff training has not been conducted for S3 which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/24/2025
Plan of Correction
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Licensee or other qualified individual to conduct required training. Licensee to provide verifiable proof to LPA by POC due date.
Type A
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on LPA record review and interviews, S1 and S2 have not completed their required annual training within the last 12 months which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/24/2025
Plan of Correction
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Licensee or qualified individual to conduct required annual training. Licensee to provide verifiable proof to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Fred Arias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2025


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 05/23/2025 05:23 PM - It Cannot Be Edited


Created By: Fred Arias On 05/23/2025 at 03:55 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 HOME CARE
FACILITY NUMBER: 306006528

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(5)(A)
Incidental Medical and Dental Care Services
(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following: (A) Medications usually prescribed for self-administration which have been authorized by the person's physician.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA record review and interviews, R5 has 2 medication pills that are missing and unaccounted for, R1 has medication that is not being administered as prescribed due to missing nebulizer, and R3 is being administered over the counter medication without a physician's order which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/24/2025
Plan of Correction
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Licensee to complete in-service training for medication administration, order nebulizer for R1, and obtain physician's orders for over the counter medication R3. Licensee to send proof of in-service training and physician's orders to LPA by POC due date.
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review and interviews, medication dosage records for R1 are not accurately being recorded and marked as administered when the medication is not available which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/24/2025
Plan of Correction
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2
3
4
Licensee to complete in-service training for medication dosage recording and send proof of training to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Fred Arias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2025


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 05/23/2025 05:23 PM - It Cannot Be Edited


Created By: Fred Arias On 05/23/2025 at 03:55 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 HOME CARE
FACILITY NUMBER: 306006528

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(l)
Admission Agreements
(l) The licensee shall attach a copy of applicable resident's rights specified by law or regulation to all admission agreements, and shall include information on the reporting of suspected or known elder and dependent abuse, as set forth in Health and Safety Code Section 1569.889.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review, R5 does not have a copy of a signed Personal Rights document in their file which pose a potential personal rights risk to persons in care.
POC Due Date: 06/06/2025
Plan of Correction
1
2
3
4
Licensee to have Resposible Party sign a Personal Rights document as required by the Department. Licensee to provide copy to LPA by due date.
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation and interview, the facility does not have any emergency water to be self sufficient for 72 hours which poses a potential health, safety risk to persons in care.
POC Due Date: 06/06/2025
Plan of Correction
1
2
3
4
Facility to purchase at least 15 gallons of water for emergency use and provide LPA with a receipt and picture.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Fred Arias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2025


LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 05/23/2025 05:23 PM - It Cannot Be Edited


Created By: Fred Arias On 05/23/2025 at 03:55 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 HOME CARE
FACILITY NUMBER: 306006528

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87207
87207 False Claims

No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review and interviews, it was revealed that staff training for S1, S2, and S3 has been falsified which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/22/2025
Plan of Correction
1
2
3
4
Licensee to provide verifiable and measurable training to all staff as required by Title 22. Licensee to provide verifable proof of training and a written Acknowlegment of Understanding document to LPA by POC due date.
Type A
Section Cited
CCR
87405(a)
87405(a) Administrator - Qualifications and Duties

...When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible...

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review and interviews, the facility does not have a qualified designated substitute which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 05/24/2025
Plan of Correction
1
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Licensee to designate a qualified substitute when Administrator if unable to fulfill their duties at the facility. Licensee to notify LPA of assignment by POC due date and provide LPA with an Acknowledgment of Understanding letter.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Fred Arias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2025


LIC809 (FAS) - (06/04)
Page: 11 of 11