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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 364700095
Report Date: 08/07/2024
Date Signed: 08/07/2024 02:26:15 PM

Document Has Been Signed on 08/07/2024 02:26 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:INDEPENDENCE ASSISTANCE INCFACILITY NUMBER:
364700095
ADMINISTRATOR/
DIRECTOR:		MONTIEL, YOLANDAFACILITY TYPE:
300
ADDRESS:278 TENNESSEE ST STE 3TELEPHONE:
(909) 798-2700
CITY:REDLANDSSTATE: CAZIP CODE:
92373
CAPACITY: CENSUS: DATE:
08/07/2024
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Sharon Whitehead, LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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Home Care Services Branch (HCSB) Analyst, Mila Quinto arrived at the business office of Independence Assistance for a post licensing inspection. Upon arrival, Analyst Quinto was greeted by licensee, Sharon Whitehead and designee, Andrew Ryan. The proper posting of business hours and license was observed. The proof of insurance's record was reviewed. The Analyst reviewed 14 HCA files and based on the file review; analyst discussed the deficiency found on 809D with the licensee.

A copy of this report and appeal rights was provided to the licensee via email.

LICENSING EVALUATOR NAME: Mila Quinto
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
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 08/07/2024 02:26 PM - It Cannot Be Edited


Created By: Mila Quinto On 08/07/2024 at 12:30 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

FACILITY NAME: INDEPENDENCE ASSISTANCE INC
FACILITY NUMBER: 364700095

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/07/2024
Section Cited
1796.14(b)
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1796.14 Scope of Requirements for HCAs (b) An affiliated home care aide shall be listed on the home care aide registry prior to providing home care services to a client.
This requirement is not met as evidenced by:
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Based on HCA file review, 9 HCAs did not have an active home care registry.
This poses an immediatey health and safety risk to the clients 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: Mila Quinto
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
LIC809 (FAS) - (06/04)
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