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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 314700024
Report Date: 01/05/2024
Date Signed: 01/10/2024 11:12:48 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/11/2023 and conducted by Evaluator Megan Vigil
COMPLAINT CONTROL NUMBER: 47-HC-20231211135922
FACILITY NAME:OPTIMISTPRIMECARE LLCFACILITY NUMBER:
314700024
ADMINISTRATOR:BUENA, JANETFACILITY TYPE:
300
ADDRESS:939 OLD RANCH HOUSE RDTELEPHONE:
(916) 895-1199
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:CENSUS: DATE:
01/05/2024
UNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Janet BuenaTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Home Care Aide provided medical services to a client.
INVESTIGATION FINDINGS:
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Home Care Services Branch (HCSB) Associate Government Program Analyst (AGPA) Megan Vigil, arrived at the business office of Optimist Prime Care LLC on 1.5.2023 at approximately 3:30 PM.

AGPA Vigil was greeted by Licensee, Janet Buena. AGPA Vigil conducted a Two Year Required Inspection and discussed the complaint allegation. Janet admitted to providing assistance to a client of a service outside the scope of non-medical services. The Home Care Services FACT sheet was provided, and Janet agreed to comply with approved services.

Based on AGPA's observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wendy Scott
LICENSING EVALUATOR NAME: Megan Vigil
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 47-HC-20231211135922
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME: OPTIMISTPRIMECARE LLC
FACILITY NUMBER: 314700024
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/05/2024
Section Cited
1796.12(n)
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..(n) "Home care services" means nonmedical services...This subdivision shall not authorize a registered home care aide to assist with medication that the client self-administers that would otherwise require administration or oversight by a licensed health care professional.
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Licensee will comply with the Home Care Services FACT Sheet that was provided as of today's date.
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Janet stated a Home Care Adie (HCA) did assist with a medical service was under the impression could assist client with the medical service. This poses an immediate Health and Safety risk to persons 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.
SUPERVISORS NAME: Wendy Scott
LICENSING EVALUATOR NAME: Megan Vigil
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
LIC9099 (FAS) - (06/04)
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