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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 304700251
Report Date: 08/29/2024
Date Signed: 08/29/2024 11:15:01 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/29/2024 11:15 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:LIFESAVERS AT HOMEFACILITY NUMBER:
304700251
ADMINISTRATOR/
DIRECTOR:		GLENN D. DAYAPFACILITY TYPE:
300
ADDRESS:800 N HARBOR BLVD, STE ATELEPHONE:
(714) 770-0608
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY: CENSUS: DATE:
08/29/2024
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Erwin Masinsin, DesigneeTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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Enforcement Analyst (EA), Mila Quinto arrived at the business office of Lifesavers at Home for a biennial inspection visit. Upon arrival, Analyst Quinto was greeted by staff, Paloma Gonzalez The proper posting of business hours and license was observed. At 10:30 am, designee, Erwin Masinsin arrived at the organization. The proof of insurance's record was reviewed. The Analyst reviewed the personnel and administrative files.

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

The analyst provided a copy of the report to the designee via email.

LICENSING EVALUATOR NAME: Mila Quinto
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
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Document Has Been Signed on 08/29/2024 11:15 AM - It Cannot Be Edited


Created By: Mila Quinto On 08/29/2024 at 10:43 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: LIFESAVERS AT HOME
FACILITY NUMBER: 304700251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2024
Section Cited
1796.44(a)
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1796.44 Training Requirements (a)(a) A licensee shall ensure that prior to providing home care services, an affiliated home care aide shall complete the training requirements...

This requirement is not met as evidenced by:
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Based on file review of 10 random HCA files, record of trainings were not available for review.
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: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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