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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194700104
Report Date: 02/25/2025
Date Signed: 02/25/2025 02:49:51 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/25/2025 02:49 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:HOME INSTEADFACILITY NUMBER:
194700104
ADMINISTRATOR/
DIRECTOR:		MEDIWAKE, RUSHIKAFACILITY TYPE:
300
ADDRESS:750 TERRADO PLAZA, SUITE 16TELEPHONE:
(626) 938-0113
CITY:COVINASTATE: CAZIP CODE:
91723
CAPACITY: CENSUS: DATE:
02/25/2025
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Rushika Mediwake - LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Home Care Services Bureau Enforcement Analyst (EA) Ryan Chan arrived at the business office of Home Instead on 2/25/25 for a biennial inspection. Upon arrival, EA was greeted by licensee Rushika Mediwake. The proper posting of business hours and license was observed. The proof of insurance's record was reviewed. EA was then shown to an area where the review of personnel and administrative files could be performed. Upon completion of the file review EA discussed the findings of the inspection with the licensee and informed her that no discrepancies were found.

EA Chan concluded the visit with an exit interview and provided a copy of this report to the licensee.

LICENSING EVALUATOR NAME: Ryan Chan
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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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