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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 344700094
Report Date: 12/09/2021
Date Signed: 03/09/2022 10:18:38 AM

Document Has Been Signed on 03/09/2022 10:18 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
CCLD Regional Office, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:CARE ON CALLFACILITY NUMBER:
344700094
ADMINISTRATOR:BATALA, NGIYANFACILITY TYPE:
300
ADDRESS:9103 LAGUNA MAIN ST #165TELEPHONE:
(408) 857-1872
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: CENSUS: DATE:
12/09/2021
Case Management - Biennial Required ContinuationUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jenny BusligTIME COMPLETED:
12:00 PM
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Home Care Services Bureau (HCSB) analyst Ruben Perez arrived at the business office of Care on Call on 12/9/2021. Upon arrival, the HCSB analyst identified himself and was greeted by Jenny Buslig. The proper posting of business hours and license was observed. The analyst was then shown to an area where the review of personnel and administrative files could be performed. Upon completion of the file review the analyst discussed the findings of the inspection with Jenny and informed the designee that no discrepancies were found.
LICENSING EVALUATOR NAME: Ruben Perez
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
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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