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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 134700003
Report Date: 07/11/2024
Date Signed: 07/11/2024 01:33:50 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/11/2024 01:33 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:HEARTS OF GOLD HOME CAREFACILITY NUMBER:
134700003
ADMINISTRATOR/
DIRECTOR:		ZENAIDA MAMERFACILITY TYPE:
300
ADDRESS:1196 GONDER RDTELEPHONE:
(760) 344-3680
CITY:BRAWLEYSTATE: CAZIP CODE:
92227
CAPACITY: CENSUS: DATE:
07/11/2024
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Fernanda ApodacaTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Home Care Services Bureau (HCSB) Analyst Adrian Mangina arrived at the business office of Hearts of Gold Home Care on July 11, 2024 for a Biennial inspection. Upon arrival, there was no one present in the office. Analyst called designee Fernanda Apodoca who arrived 30 minutes later. Upon Designee's arrival, the HCSB analyst identified herself and was greeted by Designee. The proper posting of business hours and license were 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 Designee Apodaca. The analyst informed the representative named above of the deficiencies found and explained they would be noted on the HCS809-D forms. In addition, the Designee was provided a copy of the HCS9058 Appeal Rights form.
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
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 07/11/2024 01:33 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 07/11/2024 at 12:48 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: HEARTS OF GOLD HOME CARE
FACILITY NUMBER: 134700003

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/12/2024
Section Cited
1796.45
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TB test: Home care organizations that employ..., shall submit to an examination 90 days prior to employment, or within seven days after employment, to determine that the individual is free of active tuberculosis disease. After submitting to an examination, an. affiliated home care aide whose test for tuberculosis infection shall be required to undergo an examination at least once every two years. Once an affiliated home care aide has a documented positive test for tuberculosis infection that has been followed by an X-ray, the examination is no longer required
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This requirement was not met as evidenced by:
During the review of files, it was observed that reference #8 and #9 did not have TB test results, a finding which poses an immediate health and safety risk to persons in care.
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Type A
07/12/2024
Section Cited
1796.14(a)
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An affiliated home care aide shall be listed on the home care aide registry prior to providing home care services to a client.
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This requirement was not met as evidenced by:
During the review of files, it was observed that reference #8 did not have registry listing, a finding which poses an immediate health and safety risks 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: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/11/2024 01:33 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 07/11/2024 at 01:02 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: HEARTS OF GOLD HOME CARE
FACILITY NUMBER: 134700003

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/08/2024
Section Cited
1796.44
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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...a minimum of five hours of entry-level training prior to presence with a client, as follows: two hours of orientation training regarding his or her role as caregiver and…three hours of safety training, including basic safety precautions…a minimum of five hours of annual training.
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This requirement is not met as evidenced by:
During the review of files, it was observed that all home care Aides (1,2 3, 4, 5, 6, and 7) did not have properinitial/annual training hours, a finding which poses a potential health and safety risks 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: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
LIC809 (FAS) - (06/04)
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