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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 304700150
Report Date: 12/30/2024
Date Signed: 12/30/2024 11:04:17 AM

Document Has Been Signed on 12/30/2024 11:04 AM - 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:ASSURANCE HOME CARE SERVICES INCFACILITY NUMBER:
304700150
ADMINISTRATOR/
DIRECTOR:		VINA VERASTIGUEFACILITY TYPE:
300
ADDRESS:2230 W. CHAPMAN AVE. STE. 142TELEPHONE:
(949) 370-8687
CITY:ORANGESTATE: CAZIP CODE:
92868
CAPACITY: CENSUS: DATE:
12/30/2024
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Vina Verastigue, Licensee TIME VISIT/
INSPECTION COMPLETED:
11:20 AM
NARRATIVE
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Enforcement Analyst (EA), Mila Quinto, with the Home Care Services Branch (HCSB) conducted an on site inspection for the purpose of a post licensing visit. The EA met with licensee, Vina Verastigue. The EA observed the posting of the license and operating business hours. Business operating hours are from 8am-5pm, Monday thru Friday.

During the inspection, the EA reviewed personnel records for licensee, staff 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.

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 and HCS809D), staff records review (HCS 859) and appeal rights were provided to the licensee, Vina Verastigue via email.
LICENSING EVALUATOR NAME: Mila Quinto
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2024
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 12/30/2024 11:04 AM - It Cannot Be Edited


Created By: Mila Quinto On 12/30/2024 at 10:21 AM
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: ASSURANCE HOME CARE SERVICES INC
FACILITY NUMBER: 304700150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/03/2025
Section Cited
1796.24(a)(1)
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1796.24 Maintenance of Registry; Criminal Record Review; Transfers (a) (1) The department shall establish a home care aide registry pursuant to this chapter and shall continuously update the registry information. Upon submission of the home care aide application and fingerprints or other identification documents pursuant to Section 1796.22, the department shall enter into the home care aide registry the person’s name, identification number, and an indicator that the person has submitted a home care aide application and fingerprints or identification documentation. This person shall be known as a “home care aide applicant.”
This requirement is not met as evidenced by:
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Based on file review, HCA1, HCA4 and HCA10 do not have 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: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/30/2024 11:04 AM - It Cannot Be Edited


Created By: Mila Quinto On 12/30/2024 at 10:31 AM
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: ASSURANCE HOME CARE SERVICES INC
FACILITY NUMBER: 304700150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/03/2025
Section Cited
1796.45(c)
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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. Once an affiliated home care aide has a documented positive test for tuberculosis infection that has been followed by an X-ray, the examination is no longer required.
This requirement is not met as evidenced by:
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Based on file review, HCA 8 does not have a current tb clearance. tb clearnce on file was dated 9/19/22
This poses a potential safety risk to clients in care.
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Type B
01/10/2025
Section Cited
1796.44(b)(1)
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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, as follows:
(1) Two hours of orientation training regarding his or her role as caregiver and the applicable terms of employment.
This requirement is not met as evidenced by:
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Based on the 10 HCA file review, the orientation training was missing.
This poses a potential health and 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: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2024
LIC809 (FAS) - (06/04)
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