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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 374700167
Report Date: 05/01/2025
Date Signed: 05/01/2025 10:11:55 AM

Document Has Been Signed on 05/01/2025 10:11 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:SR FAMILY IN HOME QUALITY CAREFACILITY NUMBER:
374700167
ADMINISTRATOR/
DIRECTOR:		RODRIGUEZ, LUPE SILVESTRAFACILITY TYPE:
300
ADDRESS:1326 MCDONALD ROADTELEPHONE:
(760) 497-2447
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: CENSUS: DATE:
05/01/2025
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Lupe RodriguezTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
NARRATIVE
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After multiple attempts to contact Licensee by phone and email to determine where records are kept and how to obtain access to administrative and employee files after flooding of the structure at 1326 McDonald Road, Fallbrook, CA 92028 last fall, on May 1, 2025 Enforcement Analyst (EA) of the Home Care Services Bureau (HCSB) Adrian Mangina attempted to conduct a biennial inspection at the licensed premises. The door was locked, and no one was present. EA called Licensee who stated that she could not meet EA because of an outside work commitment. Licensee stated the HCO is not operating from this address at present and has not submitted a change of location application to date.

EA advised Licensee that a change of location application must be submitted, with appropriate fee by 5/6/25 and proof of posting provided since as it has been six months since Licensee has ceased operating the Home Care Organization from this location. EA also advised that a citation will be issued to Licensee for failure to provide records after repeated inspection attempts on 6/19/2024, 11/13/24 and 5/1/25.

The analyst informed the representative named above of the deficiency found and explained they would be noted on the HCS809-D forms. In addition, Licensee Rodriguez was provided a copy of the HCS9058 Appeal Rights form via email.

NAME OF LICENSING PROGRAM ANALYST: Adrian L Mangina
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2025
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 05/01/2025 10:11 AM - It Cannot Be Edited


Created By: Adrian L Mangina On 05/01/2025 at 09:40 AM
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
Although this visit/inspection may have focused on the review of specific licensing requirements, the applicant/licensee must comply with all applicable requirements. The California Department of Social Services retains authority to issue citations or take disciplinary action for any deficiency.


FACILITY NAME: SR FAMILY IN HOME QUALITY CARE
FACILITY NUMBER: 374700167

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2025
Section Cited
1796.52(c)
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1796.52(c) An investigation or inspection conducted by the department pursuant to this chapter may include, but is not limited to, inspection of the books, records, or premises of a home care organization. A home care organization’s refusal to make records, books, or premises available shall constitute cause for the revocation of the home care organization’s license
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This requirement was not met as evidenced by: Licensee has not provided new temporary address or completed change of location application for six months and has not responded to multiple phone calls and emails requesting a meeting to review records which Licensee says are in a storage unit at an undisclosed location and is not present during regular business hours, thus was unable to provide employee files as required, which poses a potential 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: 05/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2025
LIC809 (FAS) - (06/04)
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