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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194700705
Report Date: 04/17/2024
Date Signed: 04/17/2024 03:02:30 PM

Document Has Been Signed on 04/17/2024 03:02 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:AMADA SENIOR CARE 235FACILITY NUMBER:
194700705
ADMINISTRATOR/
DIRECTOR:		PATRICK BABCOCKFACILITY TYPE:
300
ADDRESS:87 E GREEN ST # 301TELEPHONE:
(818) 350-2915
CITY:PASADENASTATE: CAZIP CODE:
91105
CAPACITY: CENSUS: DATE:
04/17/2024
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Camille MitchellTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Home Care Services Bureau (HCSB) analyst Ruben Perez and Mila Quinto arrived at the business office of Amada Senior Care 235 on April 17, 2024 for a biennial inspection. Upon arrival, the HCSB analysts identified themselves and was greeted by designee, Camille Mitchell. 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 analyst discussed the findings of the inspection with the designee. The analysts informed the designee of the deficiencies found and explained they would be noted on the 809D.
LICENSING EVALUATOR NAME: Ruben Perez
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
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 04/17/2024 03:02 PM - It Cannot Be Edited


Created By: Ruben Perez On 04/17/2024 at 02:02 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: AMADA SENIOR CARE 235
FACILITY NUMBER: 194700705

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/24/2024
Section Cited
1796.45(a)
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1796.45(a)(a) Affiliated home care aides hired on or after January 1, 2016, shall submit 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.
This requirement is not met as evidenced by:
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Based on file review, the analyst identifed missing tuberculosis test for HCA's selected in sample size. This poses a potential safety risk to the people 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: Ruben Perez
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
LIC809 (FAS) - (06/04)
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