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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 214700017
Report Date: 06/12/2024
Date Signed: 06/12/2024 02:59:15 PM

Document Has Been Signed on 06/12/2024 02:59 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:AT HOME CAREGIVERSFACILITY NUMBER:
214700017
ADMINISTRATOR/
DIRECTOR:		RUBENS, PETERFACILITY TYPE:
300
ADDRESS:7599 REDWOOD BLVD #200TELEPHONE:
(415) 898-4663
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: CENSUS: DATE:
06/12/2024
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Designee - Maureen BannisterTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Home Care Services Branch (HCSB) Analysts, Todd Borcher and Wendy Scott, arrived at the business office of At Home Caregivers for a Two-Year Licensing inspection on June 12, 2024. Upon arrival, the Analysts identified themselves and were greeted by Designee Maureen Bannister. The proper posting of business hours and license was observed. The Analysts were then shown to an area where the review of personnel and administrative files could be performed. Upon completion of the file review the Analysts discussed the findings of the inspection with the Designee. The Analysts informed the Designee of the deficiencies found and explained they would be noted on the 809D with a plan of corrections. A copy of the report was provided with appeal rights. Exit interview was conducted.
LICENSING EVALUATOR NAME: Todd Borcher
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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 06/12/2024 02:59 PM - It Cannot Be Edited


Created By: Todd Borcher On 06/12/2024 at 02:39 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: AT HOME CAREGIVERS
FACILITY NUMBER: 214700017

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2024
Section Cited
1796.44 (a)
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"A home care organization licensee shall ensure that prior to providing home care services, an affiliated home care aide shall complete the training requirements specified in this section.”

A record of completion of the required training hours and topics was not documented in one of the caregiver’s personnel records that were reviewed by HCSB analyst. This poses a potential 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: Todd Borcher
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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