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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194700052
Report Date: 02/08/2023
Date Signed: 02/08/2023 10:26:23 AM

Document Has Been Signed on 02/08/2023 10:26 AM - 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:JEDCONNET, LLC DBA HOME INSTEAD SENIOR CAREFACILITY NUMBER:
194700052
ADMINISTRATOR:CHANNTANZA FONTENOTFACILITY TYPE:
300
ADDRESS:5601 WEST SLAUSON AVE STE 255TELEPHONE:
(310) 645-8475
CITY:CULVER CITYSTATE: CAZIP CODE:
90230
CAPACITY: CENSUS: DATE:
02/08/2023
Required - 2 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Eric CarrTIME COMPLETED:
10:30 AM
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Home Care Services Bureau (HCSB) analyst Ruben Perez arrived at the business office of Home Instead Senior Care on 2/8/2023 for a biennial inspection. Upon arrival, the HCSB analyst identified himself and was greeted by Eric Carr. 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 Eric and informed the licensee that no discrepancies were found.
LICENSING EVALUATOR NAME: Ruben Perez
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2023
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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