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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 374700299
Report Date: 12/04/2024
Date Signed: 12/04/2024 12:31:02 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/04/2024 12:31 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:GOLDEN AGE CARE INCFACILITY NUMBER:
374700299
ADMINISTRATOR/
DIRECTOR:		VILLAGOMEZ, HARIMFACILITY TYPE:
300
ADDRESS:1115 TOBIAS DRTELEPHONE:
(619) 755-3854
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: CENSUS: DATE:
12/04/2024
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Harim VillagomezTIME VISIT/
INSPECTION COMPLETED:
12:45 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 Golden Age Care Inc. for a Biennial inspection. Upon arrival, the Enforcement Analyst identified herself and was greeted by Licensee Harim Villagomez.. 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. Licensee Villagomez provided Analyst with current Certificate of Insurance showing that professional liability policy, worker's compensation, and dishonesty bond are current. Ten employee files were reviewed.

Upon completion of the file review the analyst discussed the findings of the inspection with Licensee Harim Villagomez. 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)
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Document Has Been Signed on 12/04/2024 12:31 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 12/04/2024 at 11:55 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: GOLDEN AGE CARE INC
FACILITY NUMBER: 374700299

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
1796.45(a)
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TB Testing: a) Affiliated home care aides... shall submit to an examination 90 days prior to employment, or within seven days after employment, to determine that the individual is free of active tuberculosis disease.
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This requirement was not met as evidenced by:
During the review of files it was observed that reference #8 did not submit to a TB test that was within 90 days before or 7 days after employment, 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 12/04/2024 12:31 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 12/04/2024 at 12:05 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: GOLDEN AGE CARE INC
FACILITY NUMBER: 374700299

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.
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This requirement was not met as evidenced by:During the review of files it was observed that Reference #1 was missing 5 hours required annual training for 2024 and reference #2 was missing 5 hours Required Annual training for 2023 and 5 hours for 2024, 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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