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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194701037
Report Date: 09/05/2024
Date Signed: 09/05/2024 09:21:39 PM

Document Has Been Signed on 09/05/2024 09:21 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:SENIOR HELPERS WEST SAN GABRIEL VALLEYFACILITY NUMBER:
194701037
ADMINISTRATOR/
DIRECTOR:		QUOC CHANH NGUYENFACILITY TYPE:
300
ADDRESS:925 S ATLANTIC BLVD. #205ATELEPHONE:
(415) 481-8006
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91754
CAPACITY: CENSUS: DATE:
09/05/2024
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Amparo SoriaTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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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 Post Licensing 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 reviewed the personnel records for licensee, staff and Home Care Aides. Furthermore, EA reviewed the HCO’s business records including training agenda, abuse reporting incidents, current designee and insurance requirements.

During today’s visit, EA informed the HCO representative of the deficiencies found and explained they would be noted on the HCS809-D. In addition, the HCO representative was provided a copy of the LIC 9058 (Applicant/Licensee Rights) form.
LICENSING EVALUATOR NAME: Joshua Rarela
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2024
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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Document Has Been Signed on 09/05/2024 09:21 PM - It Cannot Be Edited


Created By: Joshua Rarela On 09/05/2024 at 01:49 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: SENIOR HELPERS WEST SAN GABRIEL VALLEY
FACILITY NUMBER: 194701037

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/07/2024
Section Cited
1796.45(a)(d)
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1796.45(a) (a) Affiliated home care aides hired on or after January 1, 2016, shall submit to an examination 90 days prior to employment, or within seven days after employment, to determine that the individual is free of active tuberculosis disease...(d) an affiliated home care aide shall submit, and the home care organization shall keep on file, a certificate from the examining practitioner showing that the affiliated home care aide was examined and found free from active tuberculosis disease.
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This requirement is not met as evidenced by:

Based on records review of HCA References #1, #3, #4, #5, a copy of the TB test results were not on file, which poses an a potential Health and Safety risk to persons 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: Joshua Rarela
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2024
LIC809 (FAS) - (06/04)
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