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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 304700110
Report Date: 10/18/2024
Date Signed: 10/18/2024 12:38:17 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/18/2024 12:38 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:BLUESEA CARE SERVICESFACILITY NUMBER:
304700110
ADMINISTRATOR/
DIRECTOR:		JILLIAN KENNEDY HARFOUCHEFACILITY TYPE:
300
ADDRESS:209 1/2 MAIN STTELEPHONE:
(949) 554-5411
CITY:SEAL BEACHSTATE: CAZIP CODE:
90740
CAPACITY: CENSUS: DATE:
10/18/2024
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Jullian KennedyTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
NARRATIVE
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Enforcement Analyst (EA), Mila Quinto arrived at the business office of Bluesea Care Services for biennial inspection. Upon arrival, EA Quinto was greeted by the licensee Jillian Kennedy. The proper posting of business hours and license was observed. The proof of insurance's record was reviewed. EA reviewed the personnel and administrative files.

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

EA provided a copy of the report to the designee via email.

LICENSING EVALUATOR NAME: Mila Quinto
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2024
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 3
Document Has Been Signed on 10/18/2024 12:38 PM - It Cannot Be Edited


Created By: Mila Quinto On 10/18/2024 at 12:04 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: BLUESEA CARE SERVICES
FACILITY NUMBER: 304700110

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/21/2024
Section Cited
1796.43(a)
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1796.42(a)Affiliated Home Care Aide Requirements
Home care organizations that employ affiliated home care aides shall ensure the affiliated home care aides are cleared on the home care aide registry before placing the individual in direct contact with clients.
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This requirement is not met as evidenced by:
Based on file review, HCA3 and HCA5 do not a current Home Care Registry.
This poses an immediate 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: Mila Quinto
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/18/2024 12:38 PM - It Cannot Be Edited


Created By: Mila Quinto On 10/18/2024 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: BLUESEA CARE SERVICES
FACILITY NUMBER: 304700110

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2024
Section Cited
1796.44(b)
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1796.44 Training Requirements (b)An affiliated home care aide shall complete a minimum of five hours of entry-level training prior to presence with a client...
This requirement is not met as evidenced by:
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Based on file review and interview with Licensee, HCA 6 have not completed the entry level training.
This posses a potential health and safety risk for clients in care.
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Type B
10/25/2024
Section Cited
1796.44(c)
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1796.44 Training Requirements (c)an affiliated home care aide shall complete a minimum of five hours of annual training.
This requirement is not met as evidenced by:
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Based on file review, HCA4, HCA5 are missing the required training hours.
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: Mila Quinto
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2024
LIC809 (FAS) - (06/04)
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