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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 304700377
Report Date: 03/25/2025
Date Signed: 03/25/2025 01:36:50 PM

Document Has Been Signed on 03/25/2025 01:36 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:GRISWOLD HOME CAREFACILITY NUMBER:
304700377
ADMINISTRATOR/
DIRECTOR:		BRYAN NAKAMORIFACILITY TYPE:
300
ADDRESS:2152 DUPONT DR STE 275TELEPHONE:
(949) 996-8848
CITY:IRVINESTATE: CAZIP CODE:
92612
CAPACITY: CENSUS: DATE:
03/25/2025
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Dave Penney, LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Enforcement Analyst (EA), 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 licensee, Dave Penney. The EA observed the posting of the license and operating business hours. Business operating hours are from 8:30am-4:30pm, 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, designee in the absence of the license and insurance requirements.

Based on the file review, EA informed the licensee of the deficiency found and explained they would be noted on the 809D.
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, Dave Penney via email.
NAME OF LICENSING PROGRAM ANALYST: Mila Quinto
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2025
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 03/25/2025 01:36 PM - It Cannot Be Edited


Created By: Mila Quinto On 03/25/2025 at 01:11 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: GRISWOLD HOME CARE
FACILITY NUMBER: 304700377

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/08/2025
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:
(1) Clients’ rights and safety.
(2) How to provide for, and respond to, a client’s daily living needs.
(3) How to report, prevent, and detect abuse and neglect.
(4) How to assist a client with personal hygiene and other home care services.
(5) If transportation services are provided, how to safely transport a client.
(d) The entry-level training and annual training described in subdivisions (b) and (c) may be completed through an online training program.
This requrement is not as evidenced by :
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Based on file review HCA (Ref #5) did not have the 2024 annual training available for review
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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: 03/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2025
LIC809 (FAS) - (06/04)
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