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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 374700027
Report Date: 05/19/2022
Date Signed: 05/19/2022 11:54:58 AM

Document Has Been Signed on 05/19/2022 11:54 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
CCLD Regional Office, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:HOME INSTEAD SENIOR CARE # 146FACILITY NUMBER:
374700027
ADMINISTRATOR:PAUL DZIUBANFACILITY TYPE:
300
ADDRESS:901 HACIENDA DR STE BTELEPHONE:
(760) 639-6472
CITY:VISTASTATE: CAZIP CODE:
92081
CAPACITY: CENSUS: DATE:
05/19/2022
Case Management - Biennial Required ContinuationUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Paul DziubanTIME COMPLETED:
12:00 PM
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Home Care Services Bureau (HCSB) analyst Ramsey Chimienti arrived at the business office of Home Instead Senior Care #146 on 5/19/2022. Upon arrival, the HCSB analyst identified himself and was greeted by Paul Dziuban. 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 Paul and informed the Licensee that no discrepancies were found. In addition, the Licensee was provided a printed copy of the LIC 9058 (Applicant/Licensee Rights) form.
LICENSING EVALUATOR NAME: Ramsey Chimienti
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2022
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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