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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194700976
Report Date: 10/16/2024
Date Signed: 10/17/2024 08:10:23 AM

Document Has Been Signed on 10/17/2024 08:10 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:HOME CAREGIVER COMPANIONFACILITY NUMBER:
194700976
ADMINISTRATOR/
DIRECTOR:		JENNIE LAMFACILITY TYPE:
300
ADDRESS:16881 SIMS LANE #ATELEPHONE:
(310) 648-2177
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92649
CAPACITY: CENSUS: DATE:
10/16/2024
Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Jennie Lam, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Enforcement Analyst (EA), Mila Quinto, with the Home Care Services Branch (HCSB) conducted a case management visit due to discovery from interview with licensee and record review of 2 homecare aids assisting clients without fingerprint clearance and not registered on the home care registry.

Based on EA’s interview with the licensee and record review, The following violations are being cited in accordance with Health and Safety Code 1796.23(a) Fingerprint Requirements and 1796.42(a)Home Care Aide Requirements. See HCS 809D.

A copy of this report is emailed to the licensee.

LICENSING EVALUATOR NAME: Mila Quinto
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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 10/17/2024 08:10 AM - It Cannot Be Edited


Created By: Mila Quinto On 10/16/2024 at 02:13 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: HOME CAREGIVER COMPANION
FACILITY NUMBER: 194700976

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/23/2024
Section Cited
1796.23(a)
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1796.23 Fingerprint Requirements

Fingerprint Requirements (a) Each person initiating a background examination to be a registered home care aide shall submit their fingerprints to the Department of Justice by electronic transmission in a manner approved by the department...
This requirement is not met as evidenced by:
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Based on interview and record review, licensee did not have fingerprint clearance for 2 adults hired to care for clients.
This poses an immediate health and safety risk to clients in care.
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Type A
10/23/2024
Section Cited
1796.43(a)
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1796.43 Employees, Volunteers, and Affiliated Home Care Aide Requirements
(a) Home care organizations that employ... home care aides shall ensure... home care aides are cleared on the home care aide registry before placing the individual in direct contact with clients.
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This requirement is not met as evidenced by:
Based on interview and record review, license did not have 2 adults assisting clients registered on the home care registry.
This poses an immediate health and safety risk to 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: Mila Quinto
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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