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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 304700293
Report Date: 10/04/2022
Date Signed: 10/14/2022 09:06:13 AM

Document Has Been Signed on 10/14/2022 09:06 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:CAREGIVERS TO GO HOME CAREFACILITY NUMBER:
304700293
ADMINISTRATOR:TRAGICO, POLICRONIA M.FACILITY TYPE:
300
ADDRESS:935 PROMONTORY DR. W.TELEPHONE:
(949) 529-6701
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92660
CAPACITY: CENSUS: DATE:
10/04/2022
Required - 2 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:TIME COMPLETED:
01:50 PM
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On 10/4/2022, an attempt was made to perform an unannounced inspection of Caregivers To Go Home Care. A licensee or designee shall be continuously present during the Home Care Organization’s (HCO) business office hours. Any additional incomplete inspections may result in the issuance of civil penalties or possible license revocation. Please notify your assigned analyst of any changes to the HCO location or anticipated hours of operation.
LICENSING EVALUATOR NAME: Ruben Perez
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2022
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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