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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 124700004
Report Date: 01/03/2024
Date Signed: 02/06/2024 01:20:01 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
03/28/2022 and conducted by Evaluator Megan Vigil
PUBLIC
COMPLAINT CONTROL NUMBER: 47-HC-20220328100539
FACILITY NAME:AGAPE HOME CAREFACILITY NUMBER:
124700004
ADMINISTRATOR:TRENT ZELANICKFACILITY TYPE:
300
ADDRESS:321 W WABASH AVETELEPHONE:
(707) 445-1212
CITY:EUREKASTATE: CAZIP CODE:
95501
CAPACITY:CENSUS: DATE:
01/03/2024
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Amy ZelanickTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Home Care Aide does not have TB requirements prior to caring for clients.
INVESTIGATION FINDINGS:
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Home Care Services Bureau (HCSB) Associate Government Program Analyst (AGPA) Megan Vigil arrived at the business office of Agape Home Care on 1.3.24 at approximately 2:00PM and was greeted by Designee, Amy Zelanick.

AGPA Vigil conducted an annual inspection and discussed the complaint allegation. Upon completion of the file review, it was found there was not a TB test on file for the mentioned Home Care Aide. Health and Saftey Code is cited and the deficiencies are on the attached 9099d report, an exit interview was conducted and appeal rights provided.

Based on AGPA's observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wendy Scott
LICENSING EVALUATOR NAME: Megan Vigil
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
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-20220328100539
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: AGAPE HOME CARE
FACILITY NUMBER: 124700004
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/03/2024
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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The Home Care Aide (HCA) is no longer employed by the Organization as of 4/27/22. The Licensee understands all HCA's must have a valid TB clearance on file before caring for clients.
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Home Care Organization did not have a TB test on file for a Home Care Aide. 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.
SUPERVISORS NAME: Wendy Scott
LICENSING EVALUATOR NAME: Megan Vigil
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2