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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194700647
Report Date: 08/20/2024
Date Signed: 08/20/2024 10:34:41 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/20/2024 10:34 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:SANCTUARY HOME CARE LLCFACILITY NUMBER:
194700647
ADMINISTRATOR/
DIRECTOR:		MOORE, TRACEYFACILITY TYPE:
300
ADDRESS:11623 CHANERA AVETELEPHONE:
(310) 733-9604
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY: CENSUS: DATE:
08/20/2024
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Tracey MooreTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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Home Care Services Bureau Enforcement Analysts (EA) Ryan Chan and Mila Quinto arrived at the business office of Sanctuary Home Care LLC on 8/20/24 for a biennial inspection. Upon arrival, the analysts identified themselves and were greeted by licensee Tracey Moore. The proper posting of business hours and license was observed. The analysts were then shown to an area where the review of personnel and administrative files could be performed. Upon completion of the file review the analysts discussed the findings of the inspection with the licensee. The analysts informed the licensee of the deficiencies found and explained they would be noted on the 809D. Licensee was advised that home care aides who do not have proof of negative tb should not be with clients.

Analysts 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: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024
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 08/20/2024 10:34 AM - It Cannot Be Edited


Created By: Ryan Chan On 08/20/2024 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: SANCTUARY HOME CARE LLC
FACILITY NUMBER: 194700647

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/20/2024
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...an X-ray, the examination is no longer required.
This requirement was not met as evidenced by:
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Based on records reviewed and interview with licensee, licensee failed to ensure home care aide staff (S6) completed tuberculosis test once every 2 years.
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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: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024
LIC809 (FAS) - (06/04)
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