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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 014700109
Report Date: 06/27/2024
Date Signed: 06/27/2024 12:22:38 PM

Unsubstantiated


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
05/16/2024 and conducted by Evaluator Todd Borcher
PUBLIC
COMPLAINT CONTROL NUMBER: 47-HC-20240516091346
FACILITY NAME:AGING IN PLACE HOME CAREFACILITY NUMBER:
014700109
ADMINISTRATOR:FORTUNE HUGHESFACILITY TYPE:
300
ADDRESS:3748 SELVANTE STREETTELEPHONE:
(925) 699-3788
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY:CENSUS: DATE:
06/27/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee - Fortune HughesTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Home Care Aides do not have a tuberculosis (TB) clearance.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On June 27, 2024, Home Care Services Branch (HCSB) Analyst, Todd Borcher, completed a complaint investigation, via interview, regarding the above allegation. Analyst Borcher spoke to Licensee Fortune Hughes. The analyst explained that he was finalizing a complaint investigation regarding the above complaint.

The analyst reviewed a list of documents that were made available by Licensee in order to complete the investigation. The requested documents included last available four weeks of payroll, the caregiver schedule, and personnel caregiver files.

Based on the preponderance of evidence gathered through interviews conducted, evidence obtained and observations, the above allegation was found to be UNSUBSTANTIATED. An exit interview was conducted and the licensing reports as well as the appeal rights documents were provided to the Licensee.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wendy Scott
LICENSING EVALUATOR NAME: Todd Borcher
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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