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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 304700443
Report Date: 11/13/2025
Date Signed: 11/13/2025 11:35:21 AM

Document Has Been Signed on 11/13/2025 11:35 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:AT HOME VA STAFFING LLCFACILITY NUMBER:
304700443
ADMINISTRATOR/
DIRECTOR:		RUTH TIMAFACILITY TYPE:
300
ADDRESS:1303 W VALENCIA DR #310TELEPHONE:
(213) 326-7452
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: CENSUS: DATE:
11/13/2025
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Derian King, DesigneeTIME VISIT/
INSPECTION COMPLETED:
12:00 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 biennial inspection. The EA met with the designee, Derian Williams. EA observed the posting of the license and operating business hours. Business operating hours are from 9:00 am -4:00 pm, 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. 1 of 5 HCAs did not have the criminal record clearance.

Based on the file review, EA informed the designee of the following violation observe and being cited in accordance with Health and Safety Code 1796.23(a) Fingerprint Requirements. See HCS809D.

An exit interview was conducted, a copy of this report (HCS809 and HCS809D), staff records review (HCS 859) and appeal rights were provided to the designee, Derian Williams via email.
NAME OF LICENSING PROGRAM ANALYST: Mila Quinto
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2025
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 11/13/2025 11:35 AM - It Cannot Be Edited


Created By: Mila Quinto On 11/13/2025 at 11:13 AM
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: AT HOME VA STAFFING LLC
FACILITY NUMBER: 304700443

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/20/2025
Section Cited
1796.23(a)
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1796.23 Fingerprint Requirements
(a) Each person initiating a background examination to be a registered home care aide shall submit their fingerprints to the Department of Justice by electronic transmission in a manner approved by the department...
This requirement is not met as evidenced by:
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Based on interview and file review 1 of 5 HCAs did not have the criminal background clearance.
This poses an immediate health and safety 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: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2025
LIC809 (FAS) - (06/04)
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