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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 014700195
Report Date: 04/02/2025
Date Signed: 04/09/2025 12:24:21 PM

Document Has Been Signed on 04/09/2025 12:24 PM - 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:CARE FROM HEART S CORP. DBA HOME INSTEADFACILITY NUMBER:
014700195
ADMINISTRATOR/
DIRECTOR:		LAN HSIN CHANFACILITY TYPE:
300
ADDRESS:6200 STONERIDGE MALL RD 3FTELEPHONE:
(925) 225-0220
CITY:PLEASANTONSTATE: CAZIP CODE:
94588
CAPACITY: CENSUS: DATE:
04/02/2025
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Shannon ChanTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Home Care Services Bureau (HCSB) analyst, Ruben Perez, arrived at the business office of Home Instead for an initial inspection on 4/2/2025. Upon arrival, the HCSB analyst identified himself and was greeted by Shannon Chan. 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 the analyst discussed the findings of the inspection with the licensee and informed Shannon that no discrepancies were found.
NAME OF LICENSING PROGRAM ANALYST: Ruben Perez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2025
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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Document Has Been Signed on 04/09/2025 12:24 PM - It Cannot Be Edited


Created By: Ruben Perez On 04/01/2025 at 11:46 AM
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
Although this visit/inspection may have focused on the review of specific licensing requirements, the applicant/licensee must comply with all applicable requirements. The California Department of Social Services retains authority to issue citations or take disciplinary action for any deficiency.


FACILITY NAME: CARE FROM HEART S CORP. DBA HOME INSTEAD
FACILITY NUMBER: 014700195

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/30/2025
Section Cited
1796.52 (b) (c)
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1796.52 (b) (c)
Health and Safety Code § 1796.52 (b) The department shall verify through random, unannounced inspections that a home care organization meets the requirements of this chapter and the rules and regulations promulgated pursuant to this chapter. (c) An investigation or inspection conducted by the department pursuant to this chapter may include, but is not limited to, inspection of the books, records, or premises of a home care organization. A home care organization’s refusal to make records, books, or premises available shall constitute cause for the revocation of the home care organization’s license.
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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: Ruben Perez
LICENSING EVALUATOR SIGNATURE: DATE: 04/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2025
LIC809 (FAS) - (06/04)
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