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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 374700150
Report Date: 06/18/2024
Date Signed: 06/18/2024 01:47:19 PM

Document Has Been Signed on 06/18/2024 01:47 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:AFFORDABLE AND QUALITY HOME CARE SERVICES, LLCFACILITY NUMBER:
374700150
ADMINISTRATOR/
DIRECTOR:		CINTHIA ELIZONDOFACILITY TYPE:
300
ADDRESS:1667 S MISSION RD STE AATELEPHONE:
(760) 468-3075
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: CENSUS: DATE:
06/18/2024
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Carlos PerezTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On June 18, 2024, Home Care Services Bureau (HCSB) Analyst Adrian Mangina arrived at the business office of Affordable and Quality Home Care Services LLC for a Biennial inspection. Upon arrival, the HCSB analyst identified herself and was greeted by Ezmerelda Ceja, Designee and Home Care Aide. Licensee Carlos Perez was also present. The proper posting of business hours and license was observed. Licensee was advised that regular office hours, rather that by appointment only will be required due to the need for unannounced visits. The analyst was shown to an area where the review of personnel and administrative files could be performed. Analyst observed current insurance policies and dishonesty bond. Upon completion of the file review the analyst discussed the findings of the inspection with Mr. Perez. The analyst informed the representative named above of the deficiencies found and explained they would be noted on the HCS809-D forms. In addition, the licensee was provided a copy of the HCS9058 Appeal Rights form.
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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 3
Document Has Been Signed on 06/18/2024 01:47 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 06/18/2024 at 01:05 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: AFFORDABLE AND QUALITY HOME CARE SERVICES, LLC
FACILITY NUMBER: 374700150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/19/2024
Section Cited
1796.43(a)(2)
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1796.43(a)(2)Home care organizations that employ affiliated home care aides shall …:
(2) Require home care aides to demonstrate that they are free of active tuberculosis disease, pursuant to Section 1796.45.
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This requirement was not met as evidenced by:
During the review of files, it was observed that reference #10 did not have TB test results, a finding which 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: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/18/2024 01:47 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 06/18/2024 at 01:13 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: AFFORDABLE AND QUALITY HOME CARE SERVICES, LLC
FACILITY NUMBER: 374700150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2024
Section Cited
1796.44
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1796.44 A home care organization licensee shall ensure that prior to providing home care services, an affiliated home care aide shall complete the training requirements specified in this section...a minimum of five hours of entry-level training prior to presence with a client, as follows: two hours of orientation training regarding his or her role as caregiver and…three hours of safety training, including basic safety precautions…
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This requirement was not met as evidenced by:
During the review of files, it was observed that reference #10 did not have proof of entry level training, a finding which 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: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
LIC809 (FAS) - (06/04)
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