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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 194700852
Report Date: 07/16/2024
Date Signed: 07/16/2024 12:00:41 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/03/2023 and conducted by Evaluator Ryan Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 47-HC-20231103122323
FACILITY NAME:ALEXANDRIA HOME CARE LLCFACILITY NUMBER:
194700852
ADMINISTRATOR:GRABICKI, PETERFACILITY TYPE:
300
ADDRESS:28454 N EVERGREEN LNTELEPHONE:
(509) 368-4802
CITY:SANTA CLARITASTATE: CAZIP CODE:
91390
CAPACITY:CENSUS: DATE:
07/16/2024
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Peter Grabicki - AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Home Care Organization hires 1099 home care aides.
INVESTIGATION FINDINGS:
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On 7/16/24, Home Care Services Analysts (HCSA), Ryan Chan and Mila Quinto conducted an investigation visit regarding the above complaint allegation. Upon arrival, HCSA met with Administrator Peter Grabicki.

During today’s visit, HCSA interviewed administrator who stated they employed two HCAs as1099 employees for a couple months but has stopped effective December 2023 due to liability reasons. Administrator stated he will update his advertising to remove any indication that they employ 1099 employees.

Based on analysts’s interviews, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Health and Safety Code, Division 2, Chapter 13, Section 1796.42(b) is being cited on the attached LIC 9099D.

Analysts concluded the visit with an exit interview and provided a copy of this report along with appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Susan Du
LICENSING EVALUATOR NAME: Ryan Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 47-HC-20231103122323
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME: ALEXANDRIA HOME CARE LLC
FACILITY NUMBER: 194700852
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/30/2024
Section Cited
1796.42(b)
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1796.42 (b)Maintain and abide by a valid workers’ compensation policy covering its affiliated home care aides.

This requirement was not met as evidenced by:
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Provide proof of conversion of all 1099 employees to W2 and send to your analyst stormy.yang@dss.ca.gov for your HCO. Please include your payroll report and most recent DE9C tax reporting forms.
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Based on interviews, administrator did not previously abide a valid worker's compensation policy but has since ended this practice.
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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.
SUPERVISORS NAME: Susan Du
LICENSING EVALUATOR NAME: Ryan Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2