<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194700112
Report Date: 09/19/2024
Date Signed: 09/19/2024 10:29:54 PM

Document Has Been Signed on 09/19/2024 10:29 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:1HEART CAREGIVER SERVICESFACILITY NUMBER:
194700112
ADMINISTRATOR/
DIRECTOR:		TAGARAO, KEVINFACILITY TYPE:
300
ADDRESS:16530 VENTURA BLVD STE 500TELEPHONE:
(818) 906-4441
CITY:ENCINOSTATE: CAZIP CODE:
91436
CAPACITY: CENSUS: DATE:
09/19/2024
Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Belina Calderon-NernbergTIME VISIT/
INSPECTION COMPLETED:
12:29 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Enforcement Analyst (EA), Joshua Rarela, with the Home Care Services Branch (HCSB) conducted an unannounced onsite inspection for the purpose of a Case Management visit. The EA met with the Home Care Organization (HCO) representative named above.

During the course of a complaint investigation, a deficiency was observed whereby a former Home Care Aide (HCA) of the HCO provided home care services to clients without being listed on the Home Care Aide Registry Database prior to providing home care services to clients.

Based on the information obtained, a deficiency was cited during today's visit which can be found on the attached HCS809-D form. An exit interview was conducted. A copy of this report, HCS809-D for deficiency, and appeal rights were provided.
LICENSING EVALUATOR NAME: Joshua Rarela
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 09/19/2024 10:29 PM - It Cannot Be Edited


Created By: Joshua Rarela On 09/19/2024 at 10:56 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: 1HEART CAREGIVER SERVICES
FACILITY NUMBER: 194700112

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2024
Section Cited
1796.14(b)
1
2
3
4
5
6
7
1796.14(b) An affiliated home care aide shall be listed on the home care aide registry prior to providing home care services to a client.

This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on interviews and records review, the licensee did not ensure that the HCA was registered on the HCA Registry prior to the HCA providing home care services, which poses a potential Health and Safety risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Joshua Rarela
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2