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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 074700128
Report Date: 08/26/2024
Date Signed: 08/26/2024 04:05:40 PM

Document Has Been Signed on 08/26/2024 04:05 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:BLACKHAWK HEALTHCARE INC DBA QUALICAREFACILITY NUMBER:
074700128
ADMINISTRATOR/
DIRECTOR:		MEHTA, RISHIFACILITY TYPE:
300
ADDRESS:2603 CAMINO RAMON STE 200TELEPHONE:
(949) 285-5434
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY: CENSUS: DATE:
08/26/2024
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Shona MehtaTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Associate Government Program Analyst (AGPA) Megan Vigil, arrived at the business office of Blackhawk Healthcare Inc. DBA Qualicare for a required two-year inspection.

Upon arrival, AGPA Vigil identified herself and was greeted by Licensee, Shona Mehta . 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 advised no deficiencies were found.

LICENSING EVALUATOR NAME: Megan Vigil
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2024
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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