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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194700877
Report Date: 06/03/2024
Date Signed: 06/03/2024 03:06:52 PM

Document Has Been Signed on 06/03/2024 03:06 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:LEGACY HOMECARE LAFACILITY NUMBER:
194700877
ADMINISTRATOR/
DIRECTOR:		KIDUSHIM, JASONFACILITY TYPE:
300
ADDRESS:720 WILSHIRE BLVD, SUITE 300TELEPHONE:
(949) 279-3331
CITY:SANTA MONICASTATE: CAZIP CODE:
90401
CAPACITY: CENSUS: DATE:
06/03/2024
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Zehra DhananiTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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Home Care Services Bureau (HCSB) Analyst Ryan Chan arrived at the business office of Legacy Homecare LA on 06/03/24 for a post licensing inspection. Upon arrival, Analyst Chan was greeted by Zehra Dhanani. The proper posting of business hours and license was observed. The proof of insurance record was reviewed. The Analyst was 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 Zehra Dhanani and informed her that no discrepancies were found.

Analyst Chan 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: 06/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2024
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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