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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 014700052
Report Date: 02/14/2024
Date Signed: 02/14/2024 10:29:44 AM

Document Has Been Signed on 02/14/2024 10:29 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:TRI-VALLEY PERSONAL HOME CARE SERVICESFACILITY NUMBER:
014700052
ADMINISTRATOR:GISELLE ADAMSFACILITY TYPE:
300
ADDRESS:4900 HOPYARD RD. SUITE 100TELEPHONE:
(925) 719-1548
CITY:PLEASANTONSTATE: CAZIP CODE:
94588
CAPACITY: CENSUS: DATE:
02/14/2024
Required - 2 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Gina LicupTIME COMPLETED:
11:00 AM
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Associate Government Program Analyst (AGPA) Megan Vigil arrived at the business office of Tri-Valley Home Care Services for a Required two-year inspection on 2.14.2024 at approximately 9:00am.

Upon arrival, AGPA Vigil identified herself and was greeted by Designee, Gina Licup. The proper posting of business hours and license was observed. The analyst was then shown to an area where the review of personnel and administrative files could be performed. Upon completion of the file review AGPA Vigil discussed the findings of the inspection with the Designee and informed no discrepancies were found. A copy of the report was provided with appeal rights. Exit interview was conducted.

LICENSING EVALUATOR NAME: Megan Vigil
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
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