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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 374700246
Report Date: 11/19/2024
Date Signed: 11/19/2024 12:05:30 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/19/2024 12:05 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:CARE MESA, INC.FACILITY NUMBER:
374700246
ADMINISTRATOR/
DIRECTOR:		CHIV, SCOTTFACILITY TYPE:
300
ADDRESS:330 RANCHEROS DR., STE 208TELEPHONE:
(858) 888-9632
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY: CENSUS: DATE:
11/19/2024
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Scott ChivTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On November 19, 2024, Home Care Services Bureau (HCSB) Enforcement Analyst, Adrian Mangina arrived at the business office of Care Mesa Inc. for a Biennial inspection. Upon arrival, the Enforcement Analyst noted that the office was locked. Analyst called Licensee Scott Chiv who arrived approximately one hour later. Licensee Chiv invited Analyst Mangina inside where Analyst observed the proper posting of business hours and license. The Analyst was provided an area in which the review of personnel and administrative files could be performed. Licensee provided Analyst with current Certificate of Insurance showing that professional liability policy, worker's compensation, and dishonesty bond are current. Licensee stated that there were only three active Home Care Aides and thus only three employee files were reviewed.

Upon completion of the file review the Analyst discussed the findings of the inspection with Licensee Scott Chiv 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: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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 11/19/2024 12:05 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 11/19/2024 at 10:59 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

FACILITY NAME: CARE MESA, INC.
FACILITY NUMBER: 374700246

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/20/2024
Section Cited
1796.43(a)
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(a) Home care organizations that employ affiliated home care aides shall ensure the affiliated home care aides are cleared on the home care aide registry before placing the individual in direct contact with clients.
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This requirement was not met as evidenced by:
During the review of files, it was observed that reference #3 was no affiliated on the Home Care Registry, a finding which poses an immediate health and safety risk to persons in care.
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Type A
11/20/2024
Section Cited
1796.43(a)(3)
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Employees, Volunteers, and Affiliated Home Care Aide Requirements: (a) Home care organizations that employ affiliated home care aides shall ensure...(3) Immediately notify the department when the home care organization no longer employs an individual as an affiliated home care aide.
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This requirement was not met as evidenced by:
During the review of files, it was observed that HCO has multiple Home Care Aide names affiliated that are not actively employed, 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: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
LIC809 (FAS) - (06/04)
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