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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 364700044
Report Date: 03/02/2026
Date Signed: 03/03/2026 05:25:22 PM

Document Has Been Signed on 03/03/2026 05:25 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:EXTRA HAND IN-HOME CAREFACILITY NUMBER:
364700044
ADMINISTRATOR/
DIRECTOR:		HARRY ELLIS GAINESFACILITY TYPE:
300
ADDRESS:14656 STAGELINE LANETELEPHONE:
(909) 360-2223
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: CENSUS: DATE:
03/02/2026
OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Stephanie Gaines, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Home Care Services Branch (HCSB), Enforcement Analyst (EA), Jane Cong-Huyen spoke to Stephanie Gaines to conduct a telephone pre-inspection interview. Ms. Gaines confirmed all of the HCO Information. The licensee is due for a biennial visit and has agreed to a virtual inspection visit with EA.

The virtual inspection visit is scheduled for Thursday 3/5/2026 @ 10:30am via Microsoft Teams. The HCO will be providing proof of the following information for inspection.

· Proof of Fingerprint clearance and/or proof of current HCA Registry

· Proof of TB or chest x-ray (TB test must be within 2 years period)

· Proof of HCA training (Entry Level) or (Annual Training)

· Proof of HCO Insurance: Liability insurance, Workers' Compensation, Bonds

The HCO will be receiving this report via email. HCO will send report back to EA within 24 hours with signature to confirm the virtual inspection visit.

NAME OF LICENSING PROGRAM ANALYST: Jane Cong-Huyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2026
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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