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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 304700122
Report Date: 06/05/2024
Date Signed: 06/05/2024 01:23:28 PM

Document Has Been Signed on 06/05/2024 01:23 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:ATIVA HOME CAREFACILITY NUMBER:
304700122
ADMINISTRATOR/
DIRECTOR:		PAN, KAISYFACILITY TYPE:
300
ADDRESS:18022 COWAN, SUITE 215TELEPHONE:
(949) 225-2188
CITY:IRVINESTATE: CAZIP CODE:
92614
CAPACITY: CENSUS: DATE:
06/05/2024
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Kaisy Pan and Marvin Pan, TIME VISIT/
INSPECTION COMPLETED:
01:40 PM
NARRATIVE
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Home Care Services Bureau (HCSB) Analyst, Mila Quinto arrived at the business office of Ativa Home Care for a biennial inspection visit. Upon arrival, Analyst Quinto was greeted by designee, Marvin Pan. Licensee, Kaisy Pan arrived at approximately 12:00pm. The proper posting of business hours and license was observed. The proof of insurance's record was reviewed. 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 designee and informed the designee of the deficiencies found and explained they would be noted on the 809D.
LICENSING EVALUATOR NAME: Mila Quinto
LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2024
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 06/05/2024 01:23 PM - It Cannot Be Edited


Created By: Mila Quinto On 06/05/2024 at 12:35 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: ATIVA HOME CARE
FACILITY NUMBER: 304700122

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/11/2024
Section Cited
1796.43(a)
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1796.43 Affiliated Home Care Aide Requirements. (a) Home care organizations ...shall ensure the affiliated home care aides are cleared on the home care aide registry...
This requirement is not met as evidence by:
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Based on interview and file review, HCA (Ref #9) was not registered on the HCA registry. This poses an immidiately safety risk to the 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: 06/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/05/2024 01:23 PM - It Cannot Be Edited


Created By: Mila Quinto On 06/05/2024 at 12:42 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: ATIVA HOME CARE
FACILITY NUMBER: 304700122

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/12/2024
Section Cited
1976.45(c)
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1796.45 TB Testing
(c) ... 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:
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Based on file review, the organization did not have a current tuberculosis clearance for 5 HCAs (Ref 1,3,4,6, and 9).
This poses an potential safety risk to the 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: 06/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2024
LIC809 (FAS) - (06/04)
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