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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 074700011
Report Date: 09/17/2024
Date Signed: 09/18/2024 04:04:48 PM

Document Has Been Signed on 09/18/2024 04:04 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:HOME HELPERSFACILITY NUMBER:
074700011
ADMINISTRATOR/
DIRECTOR:		ROBERT JOFACILITY TYPE:
300
ADDRESS:971 VIA VENETOTELEPHONE:
(925) 236-2477
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY: CENSUS: DATE:
09/17/2024
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Robert JoTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Associate Government Program Analyst (AGPA) Megan Vigil arrived at the business office of Home Helpers for a two-year required inspection.

Upon arrival, AGPA Vigil identified herself and was greeted by Licensee, Robert Jo. 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 and informed discrepancies were found. Advised the deficiencies found and would be noted on the 809D with a plan of corrections. A copy of the report was provided with appeal rights.

LICENSING EVALUATOR NAME: Megan Vigil
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2024
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 09/18/2024 04:04 PM - It Cannot Be Edited


Created By: Megan Vigil On 09/17/2024 at 12:58 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: HOME HELPERS
FACILITY NUMBER: 074700011

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2024
Section Cited
1796.44
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...(d) 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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Licensee was unaware of the two year requirement for TB tests. This poses an immediate Health and Safety risk to persons 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: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2024
LIC809 (FAS) - (06/04)
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