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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 364700112
Report Date: 04/22/2025
Date Signed: 04/22/2025 11:44:17 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/22/2025 11:44 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
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:FOUR HEARTS HEALTHCARE SOLUTIONS, LLCFACILITY NUMBER:
364700112
ADMINISTRATOR/
DIRECTOR:		WATSON, SHALONDAFACILITY TYPE:
300
ADDRESS:225 W HOSPITALITY LANE STE208BTELEPHONE:
(800) 606-7190
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92408
CAPACITY: CENSUS: DATE:
04/22/2025
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Shalonda Watson, LicenseeTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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 Licensing visit. The EA met with the licensee, Shalonda Watson. The EA observed the posting of the current license and operating business hours: 9am-2pm, Monday thru Wednesday.

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

Based on the file review, EA informed the licensee of the deficiency found and explained they would be noted on the 809D page. An exit interview was conducted, a copy of this report (HCS809 & HCS809D), staff records review (HCS 859) and appeal rights were provided to the licensee, Shalonda Watson, via email.
NAME OF LICENSING PROGRAM ANALYST: Jane Cong-Huyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2025
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 04/22/2025 11:44 AM - It Cannot Be Edited


Created By: Jane Cong-Huyen On 04/22/2025 at 10:38 AM
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: FOUR HEARTS HEALTHCARE SOLUTIONS, LLC
FACILITY NUMBER: 364700112

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/23/2025
Section Cited
1796.14 (b)
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1796.14(b) - (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 evidence by: based on file review. HCA #1 & #3 did not a valid home care registry. This poses an immedicate health & safety code to 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: Jane Cong-Huyen
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2025
LIC809 (FAS) - (06/04)
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