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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 214700036
Report Date: 07/09/2024
Date Signed: 07/10/2024 08:47:56 AM

Document Has Been Signed on 07/10/2024 08:47 AM - 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:C3 SERVICES LLCFACILITY NUMBER:
214700036
ADMINISTRATOR/
DIRECTOR:		MARCIAL, JERICHOFACILITY TYPE:
300
ADDRESS:900 MISSION AVE STE 2TELEPHONE:
(415) 526-3380
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: CENSUS: DATE:
07/09/2024
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Licensee - Cecil TiongTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Home Care Services Branch (HCSB) Analyst, Todd Borcher, arrived at the business office of C3 Services LLC for a Two-Year Licensing inspection on July 9, 2024. Upon arrival, the Analyst identified himself and was greeted by Licensee Cecil Tiong. The proper posting of business hours and license was observed. The Analyst was then shown to an area where the review of personnel and administrative files could be performed. Upon completion of the file review the Analyst discussed the findings of the inspection with the Licensee. The Analyst informed the Licensee 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: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2024
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 07/10/2024 08:47 AM - It Cannot Be Edited


Created By: Todd Borcher On 07/09/2024 at 12:30 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: C3 SERVICES LLC
FACILITY NUMBER: 214700036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/17/2024
Section Cited
1796.43 (a)
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“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.”

Proof of clearance on the Home Care Aide Registry was not documented in two of the caregiver’s personnel records that were reviewed by HCSB analyst. This poses an immediate health and safety risk to clients in care.
Type A
07/17/2024
Section Cited
1796.45 (a)
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“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.”

TB clearance was not documented in one of the caregiver’s personnel records that were reviewed by HCSB analyst. This poses an immediate 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: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2024
LIC809 (FAS) - (06/04)
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