<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194701067
Report Date: 05/02/2025
Date Signed: 05/02/2025 03:49:18 PM

Document Has Been Signed on 05/02/2025 03:49 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:COMFORT KEEPERS - MONROVIAFACILITY NUMBER:
194701067
ADMINISTRATOR/
DIRECTOR:		ARACELI S. SMITHFACILITY TYPE:
300
ADDRESS:517 FALLING LEAF ALLEYTELEPHONE:
(626) 254-0100
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY: CENSUS: DATE:
05/02/2025
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Jessie Hernandez - Home Care Service CoordinatorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Home Care Services Bureau Enforcement Analyst (EA) Ryan Chan arrived at the business office of Comfort Keepers Monrovia on 5/2/25 for a post licensing inspection. The HCO went through a change of ownership and retained some of the home care aides. Upon arrival, EA was greeted by Jessie Hernandez - Home Care Service Coordinator. The proper posting of business hours and license was observed. The proof of insurance's record was reviewed. EA was then shown to an area where the review of personnel and administrative files could be performed. Upon completion of the file review EA discussed the findings of the inspection with Mr. Hernandez and informed him of the deficiencies found and explained they would be noted on the 809D. Mr. Hernandez was advised that home care aides who do not have current negative TB results and who are not on the home care aide registry are not to be with clients.

EA Chan concluded the visit with an exit interview and provided a copy of this report along with appeal rights to Mr. Hernandez.

NAME OF LICENSING PROGRAM ANALYST: Ryan Chan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2025
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 05/02/2025 03:49 PM - It Cannot Be Edited


Created By: Ryan Chan On 05/02/2025 at 03:09 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
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: COMFORT KEEPERS - MONROVIA
FACILITY NUMBER: 194701067

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/09/2025
Section Cited
1796.45 (c)
1
2
3
4
5
6
7
1796.45(c) After submitting to an examination, an affiliated home care aide...shall be required to undergo an examination at least once every two years.... X-ray, the examination is no longer required.

This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on interviews and documents reviewed licensee did not ensure home care aide staff (S7) completed a TB test examination every 2 years which poses an immediate risk to the health and safety of clients in care.
8
9
10
11
12
13
14
Type A
05/09/2025
Section Cited
1796.43 (a)
1
2
3
4
5
6
7
1796.43 (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...”

This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on interviews and documents reviewed licensee did not ensure home care aide staff (S8) was cleared on the home care aide registry before placing the home care aide with clients which poses an immediate risk to the health and safety of clients in care.
8
9
10
11
12
13
14
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: 05/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2025
LIC809 (FAS) - (06/04)
Page: 2 of 2