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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194700852
Report Date: 07/16/2024
Date Signed: 07/16/2024 11:59:33 AM

Document Has Been Signed on 07/16/2024 11:59 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:ALEXANDRIA HOME CARE LLCFACILITY NUMBER:
194700852
ADMINISTRATOR/
DIRECTOR:		GRABICKI, PETERFACILITY TYPE:
300
ADDRESS:28454 N EVERGREEN LNTELEPHONE:
(509) 368-4802
CITY:SANTA CLARITASTATE: CAZIP CODE:
91390
CAPACITY: CENSUS: DATE:
07/16/2024
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Peter Grabicki - AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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Home Care Services Bureau (HCSB) Analyst Ryan Chan and Mila Quinto arrived at the business office of Alexandria Home Care LLC on 7/16/24 for a post licensing inspection. Upon arrival analysts were greeted by Licensee, Peter Grabicki. The proper posting of business hours and license was observed. The proof of insurance's record was reviewed. The Analyst was then shown to an area where the review of personnel and administrative files could be performed. The analyst informed the licensee of the deficiencies found and explained they would be noted on the 809D.

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: 07/16/2024
I acknowledge receipt of this form and understand my 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.

HCS809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 07/16/2024 11:59 AM - It Cannot Be Edited


Created By: Ryan Chan On 07/16/2024 at 10:37 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: 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
1796.44(c)
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1796.44(c) In addition to the requirements in subdivision (b), an affiliated home care aide shall complete a minimum of five hours of annual training. The annual training shall relate to core competencies and be population specific...
This requirement was not as evidenced by:
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Based on records reviewed, licensee did not have proof of completion of annual training for home care aide staff (S1 ans S3) required which poses a potential risk to the 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: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2024
LIC809 (FAS) - (06/04)
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