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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194700626
Report Date: 02/06/2025
Date Signed: 02/07/2025 10:41:54 AM

Document Has Been Signed on 02/07/2025 10:41 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: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:
02/06/2025
Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Garner Cruz, Jr. Licensee and Maria Cadag Staffing ManagerTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Home Care Services Enforcement Analyst (EA), Ryan Chan conducted a case management visit due to discovery from file review that there were home care aides missing TB test results in their files.


EA reviewed 10 home care aide (HCA) files, 2 of 10 did not have proof of negative TB test that must be conducted every 2 years required by Health and Safety Code. The TB test for the 2 HCAs are more than 2 years old. Licensee was advised and understands that HCAs can not be with clients without proof of negative TB test within 2 years.

Based on EA’s interview and records reviewed, the following deficiency is being cited in accordance with Health and Safety Code, Division 2, Chapter 13, Section 1796.45 (c). See HCS 809D.

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

LICENSING EVALUATOR NAME: Ryan Chan
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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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Document Has Been Signed on 02/07/2025 10:41 AM - It Cannot Be Edited


Created By: Ryan Chan On 02/06/2025 at 02:50 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: 02/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/10/2025
Section Cited
1796.45 (c)
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1796.45 (c) After submitting to an examination, an affiliated home care aide whose test for tuberculosis infection 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 required.
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Based on records reviewed licensee did not ensure home care aides (HCAs) S3 and S7 completed TB testing every 2 years which poses an immediate risk to the health and safety of 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: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
LIC809 (FAS) - (06/04)
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