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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 014700109
Report Date: 02/13/2024
Date Signed: 06/04/2024 11:20:22 AM

Document Has Been Signed on 06/04/2024 11:20 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: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:
02/13/2024
Required - 2 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Fortune HughesTIME COMPLETED:
03:00 PM
NARRATIVE
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Associate Government Program Analyst (AGPA) Megan Vigil arrived at the office of Aging in Place Home Care office for a Required - 2 Year Inspection on 2.13.2024 at approximately 8:50AM.

Upon arrival, AGPA Vigil identified herself and was greeted by Licensee, Fortune Hughes. 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 Licensee. Advised the deficiencies found and would be noted on the 809D with a plan of corrections. Appeal rights were provided and an exit interview was conducted.

LICENSING EVALUATOR NAME: Megan Vigil
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2024
I acknowledge receipt of this form and understand my 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.

HCS809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 06/04/2024 11:20 AM - It Cannot Be Edited


Created By: Megan Vigil On 02/13/2024 at 01:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
03/13/2024
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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Proof of clearance on the Home Care Aide(HCA) Registry was not documented in Ithe caregiver’s personnel records that were reviewed by HCSB analyst. This poses an immediate health and safety risk to clients in care.
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Type A
03/13/2024
Section Cited
1796.45 (d)
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...After each examination, an affiliated home care aide shall submit, and the home care organization shall keep on file, a certificate from the examining practitioner showing that the affiliated home care aide was examined and found free from active tuberculosis disease...
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 TB clearance was not documented in the Home Care Aide(HCA) personnel records that were reviewed by HCSB analyst. 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.
LICENSING EVALUATOR NAME: Megan Vigil
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/04/2024 11:20 AM - It Cannot Be Edited


Created By: Megan Vigil On 02/13/2024 at 01:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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 B
03/13/2024
Section Cited
1796.42 (e)
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...Report any suspected or known dependent adult or elder abuse as required by Section 15630 of the Welfare and Institutions Code and suspected... A copy of each suspected abuse report shall be maintained and available for review by the department during normal business hours...
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The signed acknowledgement to report suspected elder abuse was not documented in the Home Care Aide(HCA) personnel records that were reviewed by HCSB analyst. This poses a potential health and safety risk to clients in care.
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Type B
03/13/2024
Section Cited
1796.44 (a)
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..A home care organization licensee shall ensure that prior to providing home care services, an affiliated home care aide shall complete the training requirements specified in this section...
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A record of completion of the required training hours and topics was not documented in the Home Care Aide(HCA) personnel records that were reviewed by HCSB analyst. This poses a potential 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.
LICENSING EVALUATOR NAME: Megan Vigil
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2024
LIC809 (FAS) - (06/04)
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