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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 364700123
Report Date: 11/08/2024
Date Signed: 11/12/2024 10:18:02 AM

Document Has Been Signed on 11/12/2024 10:18 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:NU GRACE FAMILY CAREFACILITY NUMBER:
364700123
ADMINISTRATOR/
DIRECTOR:		FLOYD, GEORGINAFACILITY TYPE:
300
ADDRESS:3200 E GUASTI RD SUITE 100TELEPHONE:
(909) 637-6520
CITY:ONTARIOSTATE: CAZIP CODE:
91761
CAPACITY: CENSUS: DATE:
11/08/2024
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Georgina Floyd - HCO OwnerTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Home Care Services Bureau Enforcement Analysts (EA) Ryan Chan and Jane Cong-Huyen arrived at the business office of NU Grace Family Care on 11/8/24 for a post licensing inspection. Upon arrival, EAs identified themselves and were greeted by licensee Georgina Floyd. The proper posting of business hours and license was observed. EAs were then shown to an area where the review of personnel and administrative files could be performed. Upon completion of the file review EAs discussed the findings of the inspection with the licensee. EAs informed the licensee of the deficiencies found and explained they would be noted on the 809D.

EAs concluded the visit with an exit interview and provided a copy of this report along with appeal rights to the licensee.

LICENSING EVALUATOR NAME: Ryan Chan
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/12/2024 10:18 AM - It Cannot Be Edited


Created By: Ryan Chan On 11/08/2024 at 02:20 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: NU GRACE FAMILY CARE
FACILITY NUMBER: 364700123

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2024
Section Cited
1796.43 (a)
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1796.43(a) “Home care organizations that employ affiliated home care aides shall ensure the affiliated home care aides are cleared on the home care aide registry before placing the individual in direct contact with clients...”

This requirment is not met as evidenced by:
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Based on records reviewed licensee did not ensure that home care aides (S1 and S2) were cleared on the home care aide registry prior to placing them with clients which poses an immediate risk to the health and safety of clients in care.
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Type A
11/09/2024
Section Cited
1796.45 (d)
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1796.45(d) After each examination, an affiliated home care aide shall submit, and the home care organization shall keep on file, a certificate from the examining practitioner showing that the affiliated home care aide was examined and found free from active tuberculosis disease.
This requirement is not met as evidenced by:
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Based on records reviewed licensee did not ensure that home care aide (S4) had proof that home care aide was free from active tuberculosis prior to placing them with clients which poses an immediate risk to the health and safety of 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: Ryan Chan
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
LIC809 (FAS) - (06/04)
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