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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 304700278
Report Date: 07/15/2025
Date Signed: 07/15/2025 04:58:32 PM

Document Has Been Signed on 07/15/2025 04:58 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:AMADA SENIOR CAREFACILITY NUMBER:
304700278
ADMINISTRATOR/
DIRECTOR:		JEFFERSON, TAFAFACILITY TYPE:
300
ADDRESS:901 CALLE AMANECER STE 300TELEPHONE:
(949) 528-3500
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY: CENSUS: DATE:
07/15/2025
Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Tafa JeffersonTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On July 15, 2025, Home Care Services Bureau (HCSB) Enforcement Analyst, Adrian Mangina arrived at the business address of 901 Calle Amancer Ste 300 but the office has moved to a new address at 180 Avenida La Pata, Suite 205, San Clemente, CA 92673. Enforcement Analyst identified herself and was greeted by Designee Tafa Jefferson. EA observed that the office was being unpacked and there were no computers set up to allow for review of digital records. Analyst met with Mr. Jefferson and advised that a change of location application must be completed and mailed, along with fee within 24 hours. Additionally, Analyst requested that 10 Home Care Aide files be emailed to EA for review, as well as copies of all insurance policies no later than close of business (5:00 PM) 7/21/25.

Upon completion of the inspection visit Analyst provided a copy of this report to Designee via email.

NAME OF LICENSING PROGRAM ANALYST: Adrian L Mangina
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2025
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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