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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 364700001
Report Date: 03/20/2025
Date Signed: 03/20/2025 01:18:25 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/20/2025 01:18 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:HOME INSTEAD SENIOR CAREFACILITY NUMBER:
364700001
ADMINISTRATOR/
DIRECTOR:		BRANDI JOHNSONFACILITY TYPE:
300
ADDRESS:13334 AMARGOSA ROADTELEPHONE:
(760) 843-5655
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: CENSUS: DATE:
03/20/2025
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Nicole Herd, Office ManagerTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Enforcement Analyst (EA), Jane Cong-Huyen, with the Home Care Services Branch (HCSB) conducted an onsite inspection for the purpose of a Required 2 Year Visit. The EA met with designee, Nicole Herd. The EA observed the posting of the current license and operating business hours: 8:00am - 4:30pm, Monday thru Friday.

During the inspection, the EA reviewed personnel records for licensee, staff, and HCA staff including fingerprint clearance, HCA Registry, Tuberculosis (TB), and required training. The HCO’s business records including document for designee (HCS308) in the absence of the licensee, insurance, bond and worker's compensation requirements were also reviewed during the visit.

EA Cong-Huyen found the HCO in compliance and no deficiencies were cited. An exit interview was conducted, a copy of this report (HCS809), was provided to the HCO representative, Nicole Herd, via email.
LICENSING EVALUATOR NAME: Jane Cong-Huyen
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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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