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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194700828
Report Date: 10/17/2024
Date Signed: 10/17/2024 07:56:28 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/17/2024 07:56 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:SIGNATURE CARE PROVIDER LLCFACILITY NUMBER:
194700828
ADMINISTRATOR/
DIRECTOR:		BUSNAWI, LABAFACILITY TYPE:
300
ADDRESS:18401 BURBANK BLVD STE 220TELEPHONE:
(440) 752-4538
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY: CENSUS: DATE:
10/17/2024
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Rick AdityaTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Enforcement Analyst (EA), Joshua Rarela, with the Home Care Services Branch (HCSB) conducted an onsite inspection for the purpose of a Biennial visit. The EA met with Home Care Organization (HCO) representative named above.

During the inspection, the EA observed the posting of the license and operating business hours which show the business operates from Monday through Friday, 9AM-5PM. EA was informed by the administrator that they have not had any clients or caregivers for some time, so there are no caregiver files available. EA reviewed the HCO’s business records including training agenda, abuse reporting incidents, current designee and insurance requirements.

During today’s visit, EA found the HCO was in compliance and no deficiencies were cited. An exit interview was conducted. A copy of this report, staff records review report and the appeal rights were provided to the HCO representative.
LICENSING EVALUATOR NAME: Joshua Rarela
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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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