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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 014700109
Report Date: 02/13/2024
Date Signed: 02/16/2024 03:47:22 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/08/2023 and conducted by Evaluator Megan Vigil
PUBLIC
COMPLAINT CONTROL NUMBER: 47-HC-20230208075509
FACILITY NAME:AGING IN PLACE HOME CAREFACILITY NUMBER:
014700109
ADMINISTRATOR:FORTUNE HUGHESFACILITY TYPE:
300
ADDRESS:3748 SELVANTE STREETTELEPHONE:
(925) 699-3788
CITY:PLEASANTONSTATE: ZIP CODE:
94566
CAPACITY:CENSUS: DATE:
02/13/2024
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Fortune HughesTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Uncleared/Unregistered HCA providing care.
INVESTIGATION FINDINGS:
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Associate Government Program Analyst (AGPA) Megan Vigil arrived at the location of Aging in Place Home Care to discuss the above allegation on 2.13.2024 at approximately 8:50 AM.

Licensee, Fortune Hughes, greeted AGPA Vigil at the front door. AGPA Vigil interviewed Hughes regarding the Home Care Aide (HCA) mentioned. The client advised Hughes, the assigned HCA brought someone to cover a shift in place of the HCA, who was not registered. Hughes stated, they were notified of the issue after the incident occurred and did not report the incident because the client terminated services the same day of occurrence in January 31, 2023.

Based on AGPA's observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Health and Safety Code are being cited on the attached 9099D report and appeal rights were provided. An exit interview was conducted.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wendy Scott
LICENSING EVALUATOR NAME: Megan Vigil
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 47-HC-20230208075509
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME: AGING IN PLACE HOME CARE
FACILITY NUMBER: 014700109
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2024
Section Cited
1796.43 (a)
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...Home care organizations that employ affiliated home care aides shall ensure the affiliated home care aides are cleared on the home care aide registry before placing the individual in direct contact with clients…
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Licensee will create an acknowledgment that all current and future HCA’s will sign and date, as mentioned, no unauthorized individuals will accompany or cover a schedule shift. Will add a copy to personnel file and submit to Derek Milleman@dss.ca.gov by 3.13.24.
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Licensee scheduled a registered Home Care Aide (HCA) who brought a family member that was not employed or registered to cover the shift. Licensee was informed but did not report or document the incident. This poses an immediate health and safety risk to clients in care.
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The mentioned Home Care Aide (HCA) was not scheduled and did not provide services for the Organization from the date of the incident. Licensee will document and report any misconduct or abuse caused or intended by a HCA.
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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.
SUPERVISORS NAME: Wendy Scott
LICENSING EVALUATOR NAME: Megan Vigil
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
LIC9099 (FAS) - (06/04)
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