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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 304700348
Report Date: 10/04/2022
Date Signed: 10/04/2022 09:19:41 AM

Document Has Been Signed on 10/04/2022 09:19 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:KODA CAREGIVERSFACILITY NUMBER:
304700348
ADMINISTRATOR:SCHULTE, LYSAFACILITY TYPE:
300
ADDRESS:895 DOVE ST 3RD FLOOR STE 300TELEPHONE:
(949) 535-1111
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92660
CAPACITY: CENSUS: DATE:
10/04/2022
Annual/RandomUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Ted SchulteTIME COMPLETED:
10:00 AM
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Home Care Services Bureau (HCSB) analyst Ruben Perez arrived at the business office of Koda Caregivers on 10/4/2022. Upon arrival, the HCSB analyst identified himself and was greeted by Ted Schulte. 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 Ted and informed the licensee that no discrepancies were found. In addition, the licensee was provided a printed copy of the LIC 9058 (Applicant/Licensee Rights) form.
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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