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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 374700263
Report Date: 12/04/2024
Date Signed: 12/05/2024 07:19:57 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/05/2024 07:19 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:DEVOTED CAREGIVERS INCFACILITY NUMBER:
374700263
ADMINISTRATOR/
DIRECTOR:		ROUSSE, YAZMINFACILITY TYPE:
300
ADDRESS:3450 BONITA RD. STE 103TELEPHONE:
(619) 856-4320
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY: CENSUS: DATE:
12/04/2024
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Cecilia Hartford, Scheduling and Recruiting ManagerTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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On December 4, 2024, Home Care Services Bureau (HCSB) Enforcement Analyst, Adrian Mangina arrived at the business office of Devoted Caregivers Inc for a Biennial inspection. Upon arrival, the Enforcement Analyst identified herself and was greeted by Designee Cecilia Hartford. Analyst Mangina 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. Designee provided Analyst with proof of current professional liability policy, worker's compensation, and dishonesty bond. Twelve employee files were reviewed. Designee was advised to ensure that chest xrays be current per Statute.

Upon completion of the file review the analyst discussed the findings of the inspection with Designee Cecilia Hartford. 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: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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 12/05/2024 07:19 AM - It Cannot Be Edited


Created By: Adrian L Mangina On 12/04/2024 at 04:27 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: DEVOTED CAREGIVERS INC
FACILITY NUMBER: 374700263

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/05/2024
Section Cited
1796.44(b)
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Training Requirements:(b) An affiliated home care aide shall complete a minimum of five hours of entry-level training prior to presence with a client, as follows:
(1) Two hours of orientation training regarding his or her role as caregiver and the applicable terms of employment.
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This requirement was not met as evidenced by:
During the review of files is was observed that 12 of 12 Home Care Aides did not complete entry level training basic safety precautions and emergency procedures in files, 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: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/05/2024 07:19 AM - It Cannot Be Edited


Created By: Adrian L Mangina On 12/04/2024 at 04:34 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: DEVOTED CAREGIVERS INC
FACILITY NUMBER: 374700263

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/01/2025
Section Cited
1796.44(c)
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Training Requirements: (c) In addition to the requirements in subdivision (b), an affiliated home care aide shall complete a minimum of five hours of annual training. The annual training shall relate to core competencies and be population specific, which shall include, but not be limited to, the following areas:
(1) Clients’ rights and safety.
(2) How to provide for, and respond to, a client’s daily living needs.
(3) How to report, prevent, and detect abuse and neglect.
(4) How to assist a client with personal hygiene and other home care services.
(5) If transportation services are provided, how to safely transport a client.
(d) The entry-level training and annual training described in subdivisions (b) and (c) may be completed through an online training program.
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This requirement was not met as evidenced by:
During the review of files is was observed that reference #3 and #7 did not completed complete required annual training:(1) Clients’ rights and safety.
(2) How to provide for, and respond to, a client’s daily living needs.
(3) How to report, prevent, and detect abuse and neglect.
(4) How to assist a client with personal hygiene and other home care services.
(5) If transportation services are provided, how to safely transport a client. a finding 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: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
LIC809 (FAS) - (06/04)
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