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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 304700356
Report Date: 10/03/2022
Date Signed: 10/03/2022 02:32:35 PM

Document Has Been Signed on 10/03/2022 02:32 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:ACTI-KARE RESPONSIVE IN-HOME CARE OF IRVINEFACILITY NUMBER:
304700356
ADMINISTRATOR:VIAU, KAMARAFACILITY TYPE:
300
ADDRESS:115 W YALE LOOPTELEPHONE:
(562) 355-7314
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY: CENSUS: DATE:
10/03/2022
Annual/RandomUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Kamara ViauTIME COMPLETED:
02:30 PM
NARRATIVE
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Home Care Services Bureau (HCSB) analyst Ruben Perez arrived at the business office of Acti-Kare Responsive In Home Care of Irvine on 10/3/2022. Upon arrival, the HCSB analyst identified himself and was greeted by Kamara Viau. 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 the Kamara. The analyst informed the licensee of the deficiencies found and explained they would be noted on the 809D. 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: 10/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
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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Document Has Been Signed on 10/03/2022 02:32 PM - It Cannot Be Edited


Created By: Ruben Perez On 10/03/2022 at 01:15 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: ACTI-KARE RESPONSIVE IN-HOME CARE OF IRVINE
FACILITY NUMBER: 304700356

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/02/2022
Section Cited
1796.36 (a)(2)
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A home care organization that has its principal place of business in another state, in addition to the other requirements of this chapter, before arranging for home care services provided by an affiliated home care aide to a client in the state, shall comply with all of the following:
Maintain all pertinent records of the operation in California at the California office. All records shall be available to review, copy, audit, and inspect by the department.
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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: Ruben Perez
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
LIC809 (FAS) - (06/04)
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