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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374700014
Report Date: 10/18/2023
Date Signed: 10/18/2023 03:28:46 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/17/2023 and conducted by Evaluator Megan Vigil
PUBLIC
COMPLAINT CONTROL NUMBER: 47-HC-20230717165612
FACILITY NAME:CANAAN HOME CAREFACILITY NUMBER:
374700014
ADMINISTRATOR:JENNIFER MARSHALLFACILITY TYPE:
300
ADDRESS:731 SOUTH HWY 101 SUITE 1K1TELEPHONE:
(858) 764-2663
CITY:SOLANA BEACHSTATE: CAZIP CODE:
92075
CAPACITY:CENSUS: DATE:
10/18/2023
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Michell PetrovicTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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1. Home Care Aides are not active/registered on the Home Care Aide Registry.

2. Home Care Aides do not have current required training logged.
INVESTIGATION FINDINGS:
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Associate Government Program Analyst (AGPA) Megan Vigil met with Designee, Michell Patrovic to discuss the above allegation.

AGPA Vigil completed a record review at the location of 731 S HWY 101 SUITE 1K1, Solana Beach, CA 92075 at approximately 1:45pm.

Based on AGPA's observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Health and Safety Code Articles are being cited on the attached LIC 9099D.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wendy Scott
LICENSING EVALUATOR NAME: Megan Vigil
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 47-HC-20230717165612
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME: CANAAN HOME CARE
FACILITY NUMBER: 374700014
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/18/2023
Section Cited
1796.43
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(1) Ensure any...employee of a home care organization who has contact with clients, prospective clients, or confidential client information that may pose a risk to the clients’ ...before there is contact with clients or prospective clients or access to confidential client information.
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Scan proof of clearance in the form of a screen capture from the Home Care Aide (HCA)Registry Search site or a copy of your current personnel roster in Guardian showing registered/eligible for all employees and email to Gabriella Chavez by 10.31.23.
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Employees are not registered as an HCA through Department of Social Services. This poses an immediate Health and Safety risk to persons in care
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Any employee or caregiver cannot work until the HCA registration is cleared as of 10.18.23.
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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.
SUPERVISORS NAME: Wendy Scott
LICENSING EVALUATOR NAME: Megan Vigil
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC9099 (FAS) - (06/04)
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