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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194700084
Report Date: 05/23/2024
Date Signed: 05/23/2024 11:16:54 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/23/2024 11:16 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:ROYAL CARE COMPANIONFACILITY NUMBER:
194700084
ADMINISTRATOR/
DIRECTOR:		JASON DYFACILITY TYPE:
300
ADDRESS:17845 SAN GABRIEL AVETELEPHONE:
(562) 320-9806
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: CENSUS: DATE:
05/23/2024
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Jason DyTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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Home Care Services Bureau (HCSB) Analysts Adrian Mangina, Mila Quinto, and Ryan Chan arrived at the business office of Royal Care Companion on 5/23/2024 for a Biennial inspection. Upon arrival, the HCSB analysts rang the doorbell and identified themselves and were greeted through the microphone by Licensee Jason Dy who stated he would be there in ten minutes.

Licensee arrived at approximately 10:00 AM and admitted Analysts into the home office. The proper posting of business hours and license were observed. The analysts were then shown to an area where the review of personnel and administrative files could be performed. All insurance policies were reviewed and found to be current. Upon completion of the file review the analysts discussed the findings of the inspection with the Licensee Jason Dy. The analysts informed the representative named above of the deficiencies found and explained they would be noted on the HCS809-D forms. In addition, the Licensee was provided a copy of the 9058 Appeal Rights form.

LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
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 05/23/2024 11:16 AM - It Cannot Be Edited


Created By: Adrian L Mangina On 05/23/2024 at 10:33 AM
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: ROYAL CARE COMPANION
FACILITY NUMBER: 194700084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/30/2024
Section Cited
1796.43(a)
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 Home care organizations that employ affiliated home care aides shall …Ensure any staff person...demonstrate that they are free of active tuberculosis disease, pursuant to Section 1796.45.
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This requirement was not met as evidenced by: Based on review of files Reference#2, #3, #4, #5, #6, #7, #9, and #10 do not have record of negative TB test a finding which poses 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: 05/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/23/2024 11:16 AM - It Cannot Be Edited


Created By: Adrian L Mangina On 05/23/2024 at 10:45 AM
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: ROYAL CARE COMPANION
FACILITY NUMBER: 194700084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2024
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 file review, it was observed that Reference #3, #6, and #10 did not have initial training and References #1, #2, #4, #5, #7, #8, and #9 did not have annual training hours, a finding which poses potential health and safety risks to persons in care.
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Type B
05/30/2024
Section Cited
1796.42(e)
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A home care organization licensee shall do all of the following:Report any suspected or known dependent adult or elder abuse as required by Section 15630 of the Welfare and Institutions Code and suspected or known child abuse as required by Sections 11164 to 11174.3, inclusive, of the Penal Code. A copy of each suspected abuse report shall be maintained and available for review by the department during normal business hours.
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This requirement is not met as evidenced by:
During file review, it was observed that ten of ten Home Care Aides did not have signed Soc 341s in file a finding which poses 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: 05/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
LIC809 (FAS) - (06/04)
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