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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 304700302
Report Date: 07/11/2023
Date Signed: 07/11/2023 03:53:40 PM

Document Has Been Signed on 07/11/2023 03:53 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:HOME INSTEAD SOUTH ORANGE COUNTYFACILITY NUMBER:
304700302
ADMINISTRATOR:KORDENBROCK JR.,JAMESFACILITY TYPE:
300
ADDRESS:33161 CAMINO CAPISTRANO, STE GTELEPHONE:
(949) 347-6767
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY: CENSUS: DATE:
07/11/2023
Required - 2 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:James KordenbrockTIME COMPLETED:
04:00 PM
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Home Care Services Bureau (HCSB) analyst Ruben Perez arrived at the business office of Home Instead South Orange County on 7/11/2023 for an initial inspection. Upon arrival, the HCSB analyst identified himself and was greeted by James Kordenbrock. The proper posting of business hours and license was observed. The analyst was then shown to an area where the review of personnel and administrative files could be performed. Upon completion of the file review the analyst discussed the findings of the inspection with James and informed the licensee that no discrepancies were found.
LICENSING EVALUATOR NAME: Ruben Perez
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2023
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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