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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 334700178
Report Date: 09/24/2025
Date Signed: 09/24/2025 03:10:14 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/24/2025 03:10 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:BROOKDALE AT HOME HEMETFACILITY NUMBER:
334700178
ADMINISTRATOR/
DIRECTOR:		WOLF, KARRIEFACILITY TYPE:
300
ADDRESS:1001 N LYON AVETELEPHONE:
(951) 924-6404
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY: CENSUS: DATE:
09/24/2025
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Karrie WolfTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On September 24, 2025 , Home Care Services Bureau (HCSB) Enforcement Analyst (EA), Adrian Mangina arrived at the business office of Brookdale at Home for a Biennial inspection. Upon arrival, the Enforcement Analyst identified herself and was greeted by Designee Karrie Wolf Analyst Mangina observed the proper posting of License and business hours. The Analyst was provided with an area in which the review of personnel and administrative files could be performed. Designee provided Analyst with proof of current professional liability policy, worker's compensation, and dishonesty bond.

Upon completion of the file review the analyst discussed the findings of the inspection with Designee. The Analyst informed the representative named above of the deficiencies found and explained they would be noted on the HCS809-D form. In addition, the Licensee was provided a copy of this report and HCS9058 Appeal Rights form.

NAME OF LICENSING PROGRAM ANALYST: Adrian L Mangina
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2025
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 09/24/2025 03:10 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 09/24/2025 at 02:23 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: BROOKDALE AT HOME HEMET
FACILITY NUMBER: 334700178

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/25/2025
Section Cited
1796.43(a)
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EMPLOYEES, VOLUNTEERS, AND AFFILIATED HOME CARE AIDE REQUIREMENTS: Home care organizations that employ affiliated home care aides shall ensure the affiliated home care aides are cleared on the home care aide registry before placing the individual in direct contact with clients.
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This requirement was not met as evidenced by: During the review of files on 9/24/25, Licensee was not able to provide at time of inspection proof that reference #3 was affiliated and cleared on the California Home Care Aide registry prior to client contact Home Care Registry clearance, a finding which poses an immediate health and safety risk to persons in care.
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Type A
09/25/2025
Section Cited
1796.45(c)
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TB TESTING After submitting to an examination, an affiliated home care aide whose test for tuberculosis infection is negative shall be required to undergo an examination at least once every two years...
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This requirement was not met as evidenced by: During the review of files on 9/24/25, Licensee could not provide at time of inspection proof that Reference #2 has obtained negative TB test at least every 2 years as required, a finding which 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.
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2025
LIC809 (FAS) - (06/04)
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