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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194700394
Report Date: 10/16/2024
Date Signed: 10/16/2024 02:27:03 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/16/2024 02:27 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:FLEUR DE LIS HOME CARE INC.FACILITY NUMBER:
194700394
ADMINISTRATOR/
DIRECTOR:		MARIA G. LIMFACILITY TYPE:
300
ADDRESS:5220 CLARK AVE UNIT 105TELEPHONE:
(714) 388-5486
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY: CENSUS: DATE:
10/16/2024
Case Management - Biennial Required ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Maria Grace Lim - Owner/LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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Home Care Services Bureau Enforcement Analyst (EA) Ryan Chan arrived at the business office of Fleur De Lis Home Care Inc on 10/16/24 for a biennial inspection. Upon arrival, EA identified himself and was greeted by licensee Maria Grace Lim. 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 the licensee. The analyst informed the licensee of the deficiencies found and explained they would be noted on the 809D. Licensee was advised that home care aides (HCA) without proof of clearance on the home care aide registry are not to be with clients.

EA concluded the visit with an exit interview and provided a copy of this report along with appeal rights.

LICENSING EVALUATOR NAME: Ryan Chan
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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 3
Document Has Been Signed on 10/16/2024 02:27 PM - It Cannot Be Edited


Created By: Ryan Chan On 10/16/2024 at 01:44 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: FLEUR DE LIS HOME CARE INC.
FACILITY NUMBER: 194700394

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/17/2024
Section Cited
1796.43(a)
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1796.43(a) Home care organizations that employ affiliated home care aides shall ensure the affiliated home care aides are cleared on the home care aide registry...

This requirement is not met as evidenced by:
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Based on records reviewed HCO did not ensure that home care aide staff (S3) is cleared on the home care aide registry which poses an immediate health and safety risk to clients 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: Ryan Chan
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/16/2024 02:27 PM - It Cannot Be Edited


Created By: Ryan Chan On 10/16/2024 at 01:55 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: FLEUR DE LIS HOME CARE INC.
FACILITY NUMBER: 194700394

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/23/2024
Section Cited
1796.44(c)
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1796.44(c) In addition to the requirements in subdivision (b), an affiliated home care aide shall complete a minimum of five hours of annual training...which shall include, but not be limited to, the following...(c)(1)...(c)(2)...(c)(3)...(c)(4)...(c(5).
This requirement is not met as evidenced by:
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Based on records reviewed HCO did not ensure that home care aide staff (S3 and S4) completed annual training which poses a potential health and safety risk to clients 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: Ryan Chan
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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