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

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 244700006
Report Date: 11/09/2021
Date Signed: 11/12/2021 10:40:58 AM

Document Has Been Signed on 11/12/2021 10:40 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
CCLD Regional Office, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:KOEHN HOME CARE, INC.FACILITY NUMBER:
244700006
ADMINISTRATOR:JAYLYN KOEHNFACILITY TYPE:
300
ADDRESS:834 ZELKOVA LANETELEPHONE:
(209) 602-5695
CITY:LIVINGSTONSTATE: CAZIP CODE:
95334
CAPACITY: 0CENSUS: DATE:
11/09/2021
Case Management - Biennial Required ContinuationUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jaylyn KoehnTIME COMPLETED:
10:30 AM
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 (HCSB) Analyst Ruben Perez arrived at the business office of Koehn Home Care, Inc on 11/9/2021. Upon arrival, the HCSB analyst identified himself and was greeted by Jaylyn Koehn. 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 Jaylyn. The analyst informed her of the deficiencies found and explained they would be noted on the 809D.
LICENSING EVALUATOR NAME: Ruben Perez
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2021
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 11/12/2021 10:40 AM - It Cannot Be Edited


Created By: Ruben Perez On 11/12/2021 at 10:15 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

FACILITY NAME: KOEHN HOME CARE, INC.
FACILITY NUMBER: 244700006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2021
Section Cited
1796.37
1
2
3
4
5
6
7
(a) A home care organization that has its principal place of business in another state, in addition to the other requirements of this chapter, before arranging for home care services provided by an affiliated home care aide to a client in the state, shall comply with all of the following:
(2) Maintain all pertinent records of the operation in California at the California office. All records shall be available to review, copy, audit, and inspect by the licensing agency.
(12) Provides any other information as may be required by the department for the proper administration and enforcement of this chapter.
Type B
11/09/2021
Section Cited
1796.23
1
2
3
4
5
6
7
(a) Each person initiating a background examination to be a registered home care aide shall submit his or her fingerprints to the Department of Justice by electronic transmission in a manner approved by the State Department of Social Services, unless exempt under subdivision (d). Each person initiating a background examination to be a registered home care aide shall also submit to the State Department of Social Services a signed declaration under penalty of perjury regarding any prior criminal convictions pursuant to Section 1522 and a completed home care aide application.
Type B
11/09/2021
Section Cited
1796.42
1
2
3
4
5
6
7
(e) Report any suspected or known dependent adult or elder abuse as required by Section 15630 of the Welfare and Institutions Code and suspected or known child abuse as required by Sections 11164 to 11174.3, inclusive, of the Penal Code. A copy of each suspected abuse report shall be maintained and available for review by the department during normal business hours.
Type B
11/09/2021
Section Cited
1796.23
1
2
3
4
5
6
7
(a) Each person initiating a background examination to be a registered home care aide shall submit his or her fingerprints to the Department of Justice by electronic transmission in a manner approved by the State Department of Social Services, unless exempt under subdivision (d). Each person initiating a background examination to be a registered home care aide shall also submit to the State Department of Social Services a signed declaration under penalty of perjury regarding any prior criminal convictions pursuant to Section 1522 and a completed home care aide application.
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: Ruben Perez
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/12/2021 10:40 AM - It Cannot Be Edited


Created By: Ruben Perez On 11/12/2021 at 10:27 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

FACILITY NAME: KOEHN HOME CARE, INC.
FACILITY NUMBER: 244700006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2021
Section Cited
1796.44
1
2
3
4
5
6
7
(a) 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.
(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 regarding his or her role as caregiver and the applicable terms of employment.
(2) Three hours of safety training, including basic safety precautions, emergency procedures, and infection control.
(c) In addition to the requirements in subdivision (b), an affiliated home care aide shall complete a minimum of five hours of annual training. The annual training shall relate to core competencies and be population specific, which shall include, but not be limited to, the following areas:
(1) Clients’ rights and safety.
(2) How to provide for and respond to a client’s daily living needs.
(3) How to report, prevent, and detect abuse and neglect.
(4) How to assist a client with personal hygiene and other home care services.
(5) If transportation services are provided, how to safely transport a client.
(d) The entry-level training and annual training on department-approved job-related topics described in subdivisions (b) and (c) may be completed through an online training program.
Type B
11/09/2021
Section Cited
1796.45
1
2
3
4
5
6
7
(a) An individual hired to be an affiliated home care aide on or after January 1, 2015, shall be submitted 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 that is 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 he or she obtains documentation from a licensed medical professional that there is no risk of spreading the disease.
(c) An affiliated home care aide whose employment with a home care organization began before January 1, 2015, shall submit to the examination described in subdivision (a) before July 1, 2015.
(d) 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.
(e) After the 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.
(f) The examination is a condition of initial and continuing employment with the home care organization. The affiliated home care aide shall pay the cost of the examination.
(g) 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
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: Ruben Perez
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3