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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194700635
Report Date: 05/01/2024
Date Signed: 05/01/2024 02:19:23 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/01/2024 02:19 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:RED VINE INTERNATIONAL, INC.FACILITY NUMBER:
194700635
ADMINISTRATOR/
DIRECTOR:		WILTRUDES BIBERAFACILITY TYPE:
300
ADDRESS:11050 ARTESIA BLVD., STE. CTELEPHONE:
(562) 202-3418
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: CENSUS: DATE:
05/01/2024
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:George FedelinoTIME VISIT/
INSPECTION COMPLETED:
02:25 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 Home Care Organization (HCO) does not have any Home Care Aides employed at this time and per the licensee, they are currently only keeping the license in case they use it in the future.

The AGPAs discussed the findings of the inspection with the licensee. The AGPAs informed the licensee of
the deficiencies found and explained they would be noted on the HCS809-D. In addition, the licensee was
provided a copy of the LIC 9058 (Applicant/Licensee Rights) form.
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)
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Document Has Been Signed on 05/01/2024 02:19 PM - It Cannot Be Edited


Created By: Joshua Rarela On 05/01/2024 at 02:06 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: RED VINE INTERNATIONAL, INC.
FACILITY NUMBER: 194700635

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:

HCO stated that they currently do not keep any files for the employees, 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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