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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 364700114
Report Date: 11/16/2023
Date Signed: 11/16/2023 01:07:19 PM

Document Has Been Signed on 11/16/2023 01:07 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:INN HOME CARE LLCFACILITY NUMBER:
364700114
ADMINISTRATOR:AKUNJEH AKOFACILITY TYPE:
300
ADDRESS:11632 MOUNT WAVERLY CTTELEPHONE:
(310) 242-0652
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91737
CAPACITY: CENSUS: DATE:
11/16/2023
Post LicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jubilant AkoTIME COMPLETED:
01:00 PM
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Home Care Services Bureau (HCSB) analyst Ruben Perez arrived at the business office of Inn Home Care on 11/26/2023 for an initial inspection. Upon arrival, the HCSB analyst identified himself and was greeted by Jubilant Ako. 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 Jubilant and informed the licensee that no discrepancies were found.
LICENSING EVALUATOR NAME: Ruben Perez
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
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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