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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194700639
Report Date: 06/05/2024
Date Signed: 06/05/2024 03:19:00 PM

Document Has Been Signed on 06/05/2024 03:19 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:COMPLETE IN-HOME CARE, INC.FACILITY NUMBER:
194700639
ADMINISTRATOR/
DIRECTOR:		DENISE CUTHKELVINFACILITY TYPE:
300
ADDRESS:400 CORPORATE POINTE STE 300TELEPHONE:
(310) 403-1759
CITY:CULVER CITYSTATE: CAZIP CODE:
90230
CAPACITY: CENSUS: DATE:
06/05/2024
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:DENISE CUTHKELVINTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Home Care Services Bureau (HCSB) Analyst Ryan Chan arrived at the business office of Complete In-Home Care on 6/5/24 for an initial inspection. Upon arrival, the HCSB analyst identified himself. Analyst met with Administrator Denise Cuthkelvin. 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 administrator. The analyst informed the administrator of the deficiencies found and explained they would be noted on the 809D. Some of the Home Care Aides did not have documentation of their TB tests. Administrator was informed and understands that HCAs are not to be with and clients until proof of negative TB tests were submitted.

Analyst Chan 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: 06/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2024
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 06/05/2024 03:19 PM - It Cannot Be Edited


Created By: Ryan Chan On 06/05/2024 at 02:36 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: COMPLETE IN-HOME CARE, INC.
FACILITY NUMBER: 194700639

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/05/2024
Section Cited
1796.45(b)
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1796.45(b) For purposes of this section, “examination” means a test for tuberculosis infection...The aide shall not work as an affiliated home care aide unless the licensee obtains documentation from a licensed medical professional that there is no risk of spreading the disease.
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Based on documents reviewed and interview conducted, there is a lack of documentation that proves that HCAs have negative TB tests. This poses an immediate threat 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: 06/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2024
LIC809 (FAS) - (06/04)
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