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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 304700296
Report Date: 06/10/2025
Date Signed: 06/10/2025 01:26:42 PM

Document Has Been Signed on 06/10/2025 01:26 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:LAKE FOREST QUALITY CAREGIVERS LLCFACILITY NUMBER:
304700296
ADMINISTRATOR/
DIRECTOR:		MAHINAY, AMALIA N.FACILITY TYPE:
300
ADDRESS:22672 LAMBERT ST. STE614TELEPHONE:
(949) 616-5940
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: CENSUS: DATE:
06/10/2025
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Miguel Polintan, Office ManagerTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Enforcement Analysts (EAs), 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 the Office Manager, Miguel Polintan. The EA observed the posting of the license and operating business hours. Business operating hours are from 9:00 am -5:30pm, Monday thru Friday.

During the inspection, the EA reviewed personnel records for licensee, 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 including, the insurance requirements.

Based on the file review, EA informed the Office Manager of the following violations observe and being cited in accordance with Health and Safety Code 1796.44(b), Training Requirements and 1796.44(c) Training Requirements. See HCS809D.

An exit interview was conducted, a copy of this report (HCS809), staff records review (HCS 859) and appeal rights were provided to the licensee representative, Miguel Polintan via email.
NAME OF LICENSING PROGRAM ANALYST: Mila Quinto
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2025
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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Document Has Been Signed on 06/10/2025 01:26 PM - It Cannot Be Edited


Created By: Mila Quinto On 06/10/2025 at 12:55 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
Although this visit/inspection may have focused on the review of specific licensing requirements, the applicant/licensee must comply with all applicable requirements. The California Department of Social Services retains authority to issue citations or take disciplinary action for any deficiency.


FACILITY NAME: LAKE FOREST QUALITY CAREGIVERS LLC
FACILITY NUMBER: 304700296

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/17/2025
Section Cited
1796.44(b)
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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.
(2) Three hours of safety training, including basic safety precautions, emergency procedures, and infection control.
This requirement is not met as evidenced by:
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Based on file review staff #6(S6) did not have the entry level training available for review.
This poses a potential safety risk to clients in care.
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Type B
06/17/2025
Section Cited
1796.44(c)
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1796.44 Training Requirements
(c) In addition to the requirements in subdivision (b), an affiliated home care aide shall complete a minimum of five hours of annual training. The annual training shall relate to core competencies and be population specific, which shall include, but not be limited to, the following areas...
This requirement is not met as evidenced by:
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Based on file review, Staff#7 did not have the 2024 annual training available for review.
This poses a potential 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: 06/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2025
LIC809 (FAS) - (06/04)
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