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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194701041
Report Date: 09/26/2025
Date Signed: 09/26/2025 04:56:23 PM

Document Has Been Signed on 09/26/2025 04:56 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:GRISWOLD HOME CARE FOR SANTA CLARITAFACILITY NUMBER:
194701041
ADMINISTRATOR/
DIRECTOR:		GONZALEZ, MARY ROSEFACILITY TYPE:
300
ADDRESS:24355 LYONS AVE STE 223TELEPHONE:
(661) 936-0469
CITY:SANTA CLARITASTATE: CAZIP CODE:
91321
CAPACITY: CENSUS: DATE:
09/26/2025
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Mary Rose Gonzalez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 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 the Home Care Organization (HCO) administrator 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, 830AM to 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 administrator of the deficiencies found and explained they would be noted on the HCS809-D. A copy of this report, form HCS809-D for citation of deficiency, staff records review report and appeal rights were provided to the HCO representative electronically.
NAME OF LICENSING PROGRAM ANALYST: Joshua Rarela
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2025
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 09/26/2025 04:56 PM - It Cannot Be Edited


Created By: Joshua Rarela On 09/26/2025 at 11:00 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
Although this visit/inspection may have focused on the review of specific licensing requirements, the applicant/licensee must comply with all applicable requirements. The California Department of Social Services retains authority to issue citations or take disciplinary action for any deficiency.


FACILITY NAME: GRISWOLD HOME CARE FOR SANTA CLARITA
FACILITY NUMBER: 194701041

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/03/2025
Section Cited
1796.43(a)
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(a) Home care organizations that employ affiliated home care aides shall ensure the affiliated home care aides are cleared on the home care aide registry before placing the individual in direct contact with clients. In addition, the home care organization shall do all of the following:
(1) Ensure any staff person, volunteer, or employee of a home care organization who has contact with clients, prospective clients, or confidential client information that may pose a risk to the clients’ health and safety has met the requirements of Sections 1796.23, 1796.24, 1796.25, 1796.26, and 1796.28 before there is contact with clients or prospective clients or access to confidential client information.
(2) Require home care aides to demonstrate that they are free of active tuberculosis disease, pursuant to Section 1796.45.
(3) Immediately notify the department when the home care organization no longer employs an individual as an affiliated home care aide. (b) This section shall not prevent a licensee from requiring a criminal record clearance of any individual exempt from the requirements of this section, provided that the individual has client contact.
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This requirement is not met as evidenced by:

Based on records review, it was observed that Reference #4 had an expired HCA Registry, a finding which poses an an immediate Health and Safety risk to persons in care.
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Type A
10/03/2025
Section Cited
1796.45(a)
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(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.
(b) For purposes of this section, “examination” means a test for tuberculosis infection that is recommended by the federal Centers for Disease Control and Prevention (CDC) and licensed by the federal Food and Drug Administration (FDA) and, if that test is positive, an X-ray of the lungs. The aide shall not work as an affiliated home care aide unless the licensee obtains documentation from a licensed medical professional that there is no risk of spreading the disease.
(c) After submitting to an examination, an affiliated home care aide whose test for tuberculosis infection is negative shall be required to undergo an examination at least once every two years. Once an affiliated home care aide has a documented positive test for tuberculosis infection that has been followed by an X-ray, the examination is no longer required.
(d) After each examination, 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.
(e) The examination is a condition of initial and continuing employment with the home care organization.
(f) An affiliated home care aide who transfers employment from one home care organization to another shall be deemed to meet the requirements of subdivision (a) or (c) if the affiliated home care aide can produce a certificate showing that he or she submitted to the examination within the past two years and was found to be free of active tuberculosis disease, or if it is verified by the home care organization previously employing him or her that it has a certificate on file that contains that showing and a copy of the certificate is provided to the new home care organization prior to the affiliated home care aide beginning employment.
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This requirement is not met as evidenced by:

Based on records review, it was observed that Reference #4 did not have a proof of TB test on file, only a declaration, a finding which poses an an immediate 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: 09/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2025
LIC809 (FAS) - (06/04)
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