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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 304700400
Report Date: 03/13/2025
Date Signed: 03/13/2025 02:05:37 PM

Document Has Been Signed on 03/13/2025 02:05 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:SENIOR HELPERS OF COSTA MESAFACILITY NUMBER:
304700400
ADMINISTRATOR/
DIRECTOR:		DEREK TWELLSFACILITY TYPE:
300
ADDRESS:18384 BROOKHURST STTELEPHONE:
(562) 552-7131
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: CENSUS: DATE:
03/13/2025
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Derek Twells, LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:20 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 licensingl visit. The EA met with the licensee, Derek Twells. The EA observed the posting of the license and operating business hours. Business operating hours are from 8:00am-6:00pm, 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, Derek Twells via email.
LICENSING EVALUATOR NAME: Mila Quinto
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 03/13/2025 02:05 PM - It Cannot Be Edited


Created By: Mila Quinto On 03/13/2025 at 01:22 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: SENIOR HELPERS OF COSTA MESA
FACILITY NUMBER: 304700400

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/20/2025
Section Cited
1796.31(a)
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1796.31 Home Care Aide Renewal(a) To remain on the home care aide registry, a registered home care aide shall renew his or her registration every two years.
This requirement is not met as evidenced by:
Based on interview with licensee and file review, 2 HCAs (Ref #5 and #7) do not have a current registry.
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This poses an immediately health and safety to the 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: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/13/2025 02:05 PM - It Cannot Be Edited


Created By: Mila Quinto On 03/13/2025 at 01:27 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: SENIOR HELPERS OF COSTA MESA
FACILITY NUMBER: 304700400

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/20/2025
Section Cited
1796.44(a)
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1796.44 Training Requirements(a) A licensee shall ensure that prior to providing home care services, an affiliated home care aide shall complete the training requirements specified in this section.
This requirement is not met as evidenced by:
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Based on interivew with the licensee and file review, the 10 hca file review did not have the training records available for review.
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Type B
03/20/2025
Section Cited
1796.45(a)
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1796.45 TB Testing(a) A licensee shall ensure that prior to providing home care services, an affiliated home care aide shall complete the training requirements specified in this section.
This requirement is not met as evidenced by:
Based on interview with the licensee and file review, 5 HCAs (Ref#2, 4, 5, 7, and 9) did not have proof of the tb clearance 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: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
LIC809 (FAS) - (06/04)
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