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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194700626
Report Date: 05/01/2024
Date Signed: 05/01/2024 04:09:12 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/01/2024 04:09 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:FELICITY CARE GROUP, INC.FACILITY NUMBER:
194700626
ADMINISTRATOR/
DIRECTOR:		GARNER CRUZ JRFACILITY TYPE:
300
ADDRESS:17315 STUDEBAKER RD STE 205TELEPHONE:
(424) 319-9292
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: CENSUS: DATE:
05/01/2024
Case Management - Biennial Required ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:26 PM
MET WITH:Maria Luisa Cadag, Staffing ManagerTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On May 1, 2024, Associate Governmental Program Analysts (AGPA) Joshua Rarela and Adrian Mangina with Home Care Services Bureau arrived at the Home Care Organization (HCO) listed above. Upon arrival, the AGPAs identified themselves and was greeted by the HCO representative named above.

The proper posting of business hours and license were observed. The AGPAs were then shown to an area
where the review of personnel and administrative files could be performed. Upon completion of the file review,
the AGPAs discussed the findings of the inspection with the HCO representative. The AGPAs informed the HCO representative of the deficiencies found and explained they would be noted on the HCS809-Ds. In addition, the HCO representative was provided a copy of the LIC 9058 (Applicant/Licensee Rights) form along with this report.
LICENSING EVALUATOR NAME: Joshua Rarela
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2024
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 05/01/2024 04:09 PM - It Cannot Be Edited


Created By: Joshua Rarela On 05/01/2024 at 03:22 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: FELICITY CARE GROUP, INC.
FACILITY NUMBER: 194700626

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2024
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 the review of files, it was observed that four staff (Reference #1, 2, 3, 5, 6) did not have proper annual training hours, a finding which poses a potential health and safety risks to persons in care.
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Type B
05/31/2024
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. Once an affiliated home care aide has a documented positive test for tuberculosis infection that has been
followed by an X-ray, the examination is no longer equired…The affiliated home care aide shall pay the cost of the examination.
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This requirement is not met as evidenced by:
During the review of files, it was observed that
staff, Reference #4 and #5, did not have a TB test on file although the individuals were already tested as both are HCA registered, 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: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/01/2024 04:09 PM - It Cannot Be Edited


Created By: Joshua Rarela On 05/01/2024 at 03:54 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: FELICITY CARE GROUP, INC.
FACILITY NUMBER: 194700626

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2024
Section Cited
1796.42(e)
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A home care organization licensee shall do all of the following: (e) 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 the review of files, it was observed that
staff, Reference #1 and #4, did not have a signed
SOC341 on file, 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: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2024
LIC809 (FAS) - (06/04)
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