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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 12:25:39 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
05/16/2024 and conducted by Evaluator Todd Borcher
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):
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Home Care Aides are not approved on the Home Care Aide Registry.
INVESTIGATION FINDINGS:
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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 the 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 SUBSTANTIATED. Health and Safety Code, Division 2,
Chapter 13, Article 7, Section 1796.43(a) is being cited on the attached LIC 9099D.
Analyst Borcher concluded the visit with an exit interview and provided a copy of the HCS 9099 and 9099D investigation reports along with appeal rights.
Substantiated
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)
Page: 1 of 2
Control Number 47-HC-20240516091346
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: 06/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2024
Section Cited
1796.43 (a)
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Health and Safety Code ยง 1796.43 (a) 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. Proof of clearance on the Home Care Aide Registry
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Scan proof of clearance and registration in the form of a screen capture from the Home Care Aide Registry Search site, and payroll from May 27th, 2024 to June 9th, 2024, to Derek.Milleman@dss.ca.gov by July 29, 2024. Until proof of clearance and registration is provided, these caregivers must be immediately removed from all shifts with clients.
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was not documented for one of the previously employed caregivers who worked shifts with client(s). This poses an immediate health and safety risk to clients in care.
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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: 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
LIC9099 (FAS) - (06/04)
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