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

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 304700068
Report Date: 02/19/2025
Date Signed: 02/19/2025 12:44:45 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/19/2025 12:44 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:LAKE FOREST HOME CARE, INC.FACILITY NUMBER:
304700068
ADMINISTRATOR/
DIRECTOR:		REZAI, SAEIDFACILITY TYPE:
300
ADDRESS:23121 VERDUGO DRIVE SUITE 202TELEPHONE:
(949) 305-2431
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: CENSUS: DATE:
02/19/2025
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:Moe Fayez, licenseeTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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
Enforcement Analyst (EA), Mila Quinto, with the Home Care Services Branch (HCSB) conducted an on site inspection for the purpose of a biennial visit. The EA met with the licensee, Moe Fayez. The EA observed the posting of the license and operating business hours. Business operating hours are from 9am-5pm, Monday thru Friday.

During the inspection, the EA reviewed personnel records for licensee, and Home Care Aides including fingerprint status', registry status', Tuberculosis (TB), and required training. The HCO’s business records were also reviewed during the visit including, designee in the absence of the license and insurance requirements.

Based on the file review, EA informed the licensee of the deficiency found and explained they would be noted on the 809D.

An exit interview was conducted, a copy of this report (HCS809), staff records review (HCS 859) and appeal rights were provided to the licensee, Moe Fayez via email.
LICENSING EVALUATOR NAME: Mila Quinto
LICENSING EVALUATOR SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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 02/19/2025 12:44 PM - It Cannot Be Edited


Created By: Mila Quinto On 02/19/2025 at 12:17 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: LAKE FOREST HOME CARE, INC.
FACILITY NUMBER: 304700068

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2025
Section Cited
1796.45(c)
1
2
3
4
5
6
7
1796.45 TB Testing(c) 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.
This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on file review, HCA 8 did not have a current tb clearance available for review.
This poses a potentail health and safety risk to clients in care.
8
9
10
11
12
13
14
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: Mila Quinto
LICENSING EVALUATOR SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
LIC809 (FAS) - (06/04)
Page: 2 of 2