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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194700581
Report Date: 06/27/2024
Date Signed: 06/28/2024 08:25:38 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/28/2024 08:25 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:EXTRACAREFACILITY NUMBER:
194700581
ADMINISTRATOR/
DIRECTOR:		BETELHEM SHIFERAWFACILITY TYPE:
300
ADDRESS:9236 GERALD AVETELEPHONE:
(310) 634-3173
CITY:NORTHRIDGESTATE: CAZIP CODE:
91343
CAPACITY: CENSUS: DATE:
06/27/2024
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Betelhem ShiferawTIME VISIT/
INSPECTION COMPLETED:
10:50 AM
NARRATIVE
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On June 27, 2024, Associate Governmental Program Analyst (AGPA) Joshua Rarela with Home Care Services Branch arrived at the Home Care Organization (HCO) listed above. Upon arrival, the
AGPA identified himself and was greeted by licensee named above.

The proper posting of business hours and license were observed. The AGPA was shown to an area
where the review of personnel and administrative files could be performed. Upon completion of the file review, the AGPA discussed the findings of the inspection with the licensee. The AGPA informed the licensee of the deficiency found and explained it would be noted on the HCS809-D.

AGPA provided the licensee a copy of this report, HCS809-D, HCS859, and Appeal Rights.
LICENSING EVALUATOR NAME: Joshua Rarela
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
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 06/28/2024 08:25 AM - It Cannot Be Edited


Created By: Joshua Rarela On 06/27/2024 at 10:20 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: EXTRACARE
FACILITY NUMBER: 194700581

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/27/2024
Section Cited
1796.45(a)
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An individual hired to be an affiliated home care aide…shall be submitted to an examination 90 days prior to employment or within seven days after employment to determine that the individual is free of active tuberculosis disease…an affiliated home
care aide whose test for tuberculosis infection is negative shall be required to undergo an examination at least once every two years.
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This requirement is not met as evidenced by:

Upon review of the files, the AGPA observed that the licensee, who provide home care services, had an expired TB Test, a finding which poses a 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: Joshua Rarela
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
LIC809 (FAS) - (06/04)
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