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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 374700014
Report Date: 10/18/2023
Date Signed: 10/18/2023 03:27:33 PM

Document Has Been Signed on 10/18/2023 03:27 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: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
Required - 2 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Michelle PetrovicTIME COMPLETED:
03:00 PM
NARRATIVE
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Home Care Services Bureau (HCSB) Associate Government Program Analyst (AGPA) Megan Vigil arrived at the business office of Canaan Home Care on 10.18.23 at approximately 1:30pm. Upon arrival, AGPA Vigil identified herself and was greeted by Designee, Michelle Petrovic. 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. The proof of insurance's record was reviewed. Upon completion of the file review the analyst discussed the findings of the inspection with Designee. The analyst informed the deficiencies found and explained they would be noted on the 809D.
LICENSING EVALUATOR NAME: Megan Vigil
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2023
I acknowledge receipt of this form and understand my 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.

HCS809 (FAS) - (06/04)
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Document Has Been Signed on 10/18/2023 03:27 PM - It Cannot Be Edited


Created By: Megan Vigil On 10/18/2023 at 02:36 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: 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
10/31/2023
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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Employee is 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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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: Megan Vigil
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2023
LIC809 (FAS) - (06/04)
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