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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 244700006
Report Date: 05/01/2026
Date Signed: 05/01/2026 01:13:11 PM

Document Has Been Signed on 05/01/2026 01:13 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:KOEHN HOME CARE, INC.FACILITY NUMBER:
244700006
ADMINISTRATOR/
DIRECTOR:		JAYLYN KOEHNFACILITY TYPE:
300
ADDRESS:834 ZELKOVA LANETELEPHONE:
(209) 602-5695
CITY:LIVINGSTONSTATE: CAZIP CODE:
95334
CAPACITY: CENSUS: DATE:
05/01/2026
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Jaylyn KoehnTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Enforcement Analyst (EA) Ruben Perez conducted a virtual visit and met with the licensee Jay. During the visit, EA verified the posting of the license, observed the operation of the business, confirmed compliance with insurance requirements, and completed the required personnel file review. All requested documentation was provided and reviewed.

After reviewing all personnel files, the analyst identified decifiencies that were noted on the 809D. An exit interview was conducted, and copies of 809 Facility Evaluation, 859 Staff Records Review Report, and appeal rights information were provided via email.

NAME OF LICENSING PROGRAM ANALYST: Ruben Perez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2026
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 05/01/2026 01:13 PM - It Cannot Be Edited


Created By: Ruben Perez On 05/01/2026 at 12:54 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: KOEHN HOME CARE, INC.
FACILITY NUMBER: 244700006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/15/2026
Section Cited
1796.45 (a)
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Health and Safety Code § 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. TB clearance 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.
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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: Ruben Perez
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2026
LIC809 (FAS) - (06/04)
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