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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 304700015
Report Date: 07/12/2023
Date Signed: 07/12/2023 01:06:45 PM

Document Has Been Signed on 07/12/2023 01:06 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:LEISURE CARE HOME CARE AGENCY, INC.FACILITY NUMBER:
304700015
ADMINISTRATOR:BLACKANN, TREVORFACILITY TYPE:
300
ADDRESS:30131 TOWN CENTER DR SUITE 205TELEPHONE:
(949) 363-7401
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: CENSUS: DATE:
07/12/2023
Required - 2 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Blair WeissTIME COMPLETED:
01:15 PM
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Home Care Services Bureau (HCSB) analyst Ruben Perez arrived at the business office of Leisure Care Home Care Agency on 7/12/2023 for a biennial inspection. Upon arrival, the HCSB analyst identified himself and was greeted by Blair Weiss. 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 Blair and informed the designee that no discrepancies were found.
LICENSING EVALUATOR NAME: Ruben Perez
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2023
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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