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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 374700176
Report Date: 07/01/2024
Date Signed: 07/01/2024 04:19:59 PM

Document Has Been Signed on 07/01/2024 04:19 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:GOOD CARE PERSONAL CARE SERVICESFACILITY NUMBER:
374700176
ADMINISTRATOR/
DIRECTOR:		JONES, MARILYNFACILITY TYPE:
300
ADDRESS:3124 BRILENE LANETELEPHONE:
(858) 342-8091
CITY:SAN DIEGOSTATE: CAZIP CODE:
92111
CAPACITY: CENSUS: DATE:
07/01/2024
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Marilyn JonesTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Home Care Services Bureau (HCSB) Analyst Adrian Mangina arrived at the business office of Good Care Personal Care Services on July 1, 2024 for a Biennial inspection. Upon arrival, the HCSB analyst identified herself and was greeted by Licensee Marilyn Jones. The proper posting of business hours and license were observed. The analyst was then shown to an area where the review of administrative files could be performed. Licensee stated that her personnel files reside at a family member's home who helps with the paperwork. Licensee was advised that all files must be located in the office address on file. Analyst was unable to review personnel files as they were offsite, but was able to view current liability and worker's compensation insurance, as well as dishonesty bond. The analyst discussed the findings of the inspection with the Marilyn Jones Analyst informed the representative named above of the deficiencies found and explained they would be noted on the HCS809-D form. In addition, the licensee was provided a copy of the HCS9058 Appeal Rights form.
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2024
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 07/01/2024 04:19 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 07/01/2024 at 03:23 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: GOOD CARE PERSONAL CARE SERVICES
FACILITY NUMBER: 374700176

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/02/2024
Section Cited
1796.52(b)
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1796.52(b)
(b) The department shall verify through random, unannounced inspections that a home care organization meets the requirements of this chapter and the rules and regulations promulgated pursuant to this chapter.
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This requirement was not met as evidenced by:
Licensee was unable to provide staff files as files are not located at office for review 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: 07/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2024
LIC809 (FAS) - (06/04)
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