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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 304700023
Report Date: 01/29/2024
Date Signed: 01/29/2024 12:24:04 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/29/2024 12:24 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:HOMEWATCH CAREGIVERS OF HUNTINGTON BEACHFACILITY NUMBER:
304700023
ADMINISTRATOR:KYLE ROBAR OR KAMI BALDWINFACILITY TYPE:
300
ADDRESS:20902 BROOKHURST ST STE 204TELEPHONE:
(714) 656-3044
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY: CENSUS: DATE:
01/29/2024
Required - 2 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kyle RobarTIME COMPLETED:
12:30 PM
NARRATIVE
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Home Care Services Bureau (HCSB) analyst, Ramsey Chimienti, arrived at the business office of Homewatch Caregivers Of Huntington Beach for a biennial inspection on 1/29/24. Upon arrival, the HCSB analyst identified himself and was greeted by Kyle Robar. 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 Mr. Robar. The analyst informed the Licensee of the deficiencies found and explained they would be noted on the 809D.
LICENSING EVALUATOR NAME: Ramsey Chimienti
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024
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 2
Document Has Been Signed on 01/29/2024 12:24 PM - It Cannot Be Edited


Created By: Ramsey Chimienti On 01/29/2024 at 12:11 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: HOMEWATCH CAREGIVERS OF HUNTINGTON BEACH
FACILITY NUMBER: 304700023

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/06/2024
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 five of the caregiver’s personnel records that were reviewed by HCSB analyst. This poses a ealth and safety risk to clients in care.
Type B
03/01/2024
Section Cited
1796.42 (e)
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Health and Safety Code § 1796.42 (e) A home care organization licensee shall do all of the following:
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. Signed acknowledgement to report suspected elder abuse was not documented in two 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: Ramsey Chimienti
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024
LIC809 (FAS) - (06/04)
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