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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 304700305
Report Date: 09/19/2024
Date Signed: 09/19/2024 03:14:22 PM

Document Has Been Signed on 09/19/2024 03:14 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:SYNERGY HOMECARE OF HUNTINGTON BEACHFACILITY NUMBER:
304700305
ADMINISTRATOR/
DIRECTOR:		MICHAEL MANTONGFACILITY TYPE:
300
ADDRESS:16152 BEACH BLVD #279TELEPHONE:
(714) 509-1880
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY: CENSUS: DATE:
09/19/2024
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Michael Montong, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Enforcement Analyst (EA), Mila Quinto arrived at the business office of Synergy Homecare of Huntington Beach for a post licensing inspection. Upon arrival, Analyst Quinto was greeted by the licensee, Michael Mantong. The proper posting of business hours and license was observed. The proof of insurance's record was reviewed. The Analyst reviewed the personnel and administrative files.

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

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

LICENSING EVALUATOR NAME: Mila Quinto
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
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 09/19/2024 03:14 PM - It Cannot Be Edited


Created By: Mila Quinto On 09/19/2024 at 02:56 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

FACILITY NAME: SYNERGY HOMECARE OF HUNTINGTON BEACH
FACILITY NUMBER: 304700305

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2024
Section Cited
1796.45(a)
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1796.45(a) Affiliated home care aides hired... shall submit to an examination 90 days prior to employment, or within seven days after employment, to determine that the individual is free of active tuberculosis disease.
This requirement is not met as evidenced by:
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Based on file review, HCA #5 did not have tb clearance on file.
This poses a potential 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: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
LIC809 (FAS) - (06/04)
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