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

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194701104
Report Date: 06/20/2025
Date Signed: 06/20/2025 03:29:14 PM

Document Has Been Signed on 06/20/2025 03:29 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:LUCKY CHARM HOME CARE SERVICESFACILITY NUMBER:
194701104
ADMINISTRATOR/
DIRECTOR:		AVELINA VILLEGASFACILITY TYPE:
300
ADDRESS:1442 E 215TH STREETTELEPHONE:
(310) 525-8876
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: CENSUS: DATE:
06/20/2025
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Avelina Villegas - LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:45 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 Lucky Charm Home Care Services on 6/20/25 for a post licensing inspection. EA met with licensee Avelina Villegas. 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 the licensee. EA informed the licensee of the deficiencies found and explained they would be noted on the 809D. EA advised that home care aides who do not have valid proof of negative tuberculosis test are not to be with clients. EA also advised that home care aides who have not been cleared 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 the licensee.

NAME OF LICENSING PROGRAM ANALYST: Ryan Chan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2025
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 3
Document Has Been Signed on 06/20/2025 03:29 PM - It Cannot Be Edited


Created By: Ryan Chan On 06/20/2025 at 02:53 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: LUCKY CHARM HOME CARE SERVICES
FACILITY NUMBER: 194701104

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2025
Section Cited
1796.45a
1
2
3
4
5
6
7
1796.45(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.
This requirement is not met as evidenced by
8
9
10
11
12
13
14
Based on records reviewed licensee did not ensure home care aides (S2, S3, S5, S6) were free from active tuberculosis before placing them with clients which poses an immediate risk to the health nd safety of clients in care.
8
9
10
11
12
13
14
Type A
06/30/2025
Section Cited
1796.43(a)
1
2
3
4
5
6
7
1796.43 (a)
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 is not met as evidenced by:

8
9
10
11
12
13
14
Based on records reviewed licensee did not ensure home care aides (S4 and S5) were cleared on the home care aide registry before placing the individual in direct contact with clients which poses an immediate risk to the health nd 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: 06/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/20/2025 03:29 PM - It Cannot Be Edited


Created By: Ryan Chan On 06/20/2025 at 03:11 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: LUCKY CHARM HOME CARE SERVICES
FACILITY NUMBER: 194701104

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2025
Section Cited
1796.44(b)
1
2
3
4
5
6
7
1796.44(b) An affiliated home care aide shall complete a minimum of five hours of entry-level training prior to presence with a client, as follows:(1) Two hours of orientation training...(2) Three hours of safety training..., including basic safety...
THis requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on records reviewed licensee did not ensure home care aides completed entry level training prior to prescence with clients which poses a potential risk to the health and safety of clients in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 06/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3