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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 374700281
Report Date: 06/03/2024
Date Signed: 06/03/2024 10:39:31 AM

Document Has Been Signed on 06/03/2024 10:39 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:HANNAH'S ANGELIC CARE LLCFACILITY NUMBER:
374700281
ADMINISTRATOR/
DIRECTOR:		BENJAMIN, JANE AGAYANFACILITY TYPE:
300
ADDRESS:8003 WINTER GARDENS BLVD 209TELEPHONE:
(619) 792-6492
CITY:EL CAJONSTATE: CAZIP CODE:
92021
CAPACITY: CENSUS: DATE:
06/03/2024
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Jane Agayan BenjaminTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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Home Care Services Bureau (HCSB) Analyst, Adrian Mangina arrived at the business office of Hannah's Angelic Care on June 3, 2024 for a post licensing inspection. Upon arrival, Analyst Mangina was greeted by Licensee Jane Agayan Benjamin. The proper posting of business hours and license was observed. The Analyst was then shown to an area where the review of personnel and administrative files could be performed. Licensee does not currently have any employees but was advised that all employees must have fingerprint clearances and TB tests (initial and every 2 years) and all Home Care Aides must additionally have initial and annual training (5 hours), signed SOC341, and be registered and renewed biennially on the Home Care Aide Registry Upon completion of the file review 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: 06/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2024
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 06/03/2024 10:39 AM - It Cannot Be Edited


Created By: Adrian L Mangina On 06/03/2024 at 10:08 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: HANNAH'S ANGELIC CARE LLC
FACILITY NUMBER: 374700281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2024
Section Cited
1796.43(a)(2)
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Home care organizations that employ affiliated home care aides shall …:Require home care aides to demonstrate that they are free of active tuberculosis disease, pursuant to Section 1796.45.
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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: 06/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/03/2024 10:39 AM - It Cannot Be Edited


Created By: Adrian L Mangina On 06/03/2024 at 10:15 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: HANNAH'S ANGELIC CARE LLC
FACILITY NUMBER: 374700281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2024
Section Cited
1796.42(c)
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A home care organization licensee shall:Maintain and abide by an employee dishonesty bond, including third-party coverage, with a minimum limit of ten thousand dollars ($10,000).
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This requirement was not met as evidenced by:
During the review of files, it was observed that Licensee could not locate dishonesty bond a finding which poses a potential health and safety risks to persons in care
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Type B
06/10/2024
Section Cited
1796.42(d)
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A home care organization licensee shall:Maintain proof of general and professional liability insurance in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the aggregate.
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This requirement was not met as evidenced by:
During the review of files, it was observed that Licensee could not Liability Insurance policy a finding which poses a potential health and safety risks 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: 06/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2024
LIC809 (FAS) - (06/04)
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