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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 374700357
Report Date: 08/26/2025
Date Signed: 08/26/2025 02:06:07 PM

Document Has Been Signed on 08/26/2025 02:06 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:BAYSIDE RESPITE CARE LLCFACILITY NUMBER:
374700357
ADMINISTRATOR/
DIRECTOR:		RANNA KRAWCZYKFACILITY TYPE:
300
ADDRESS:9346 TELKAIF ST.TELEPHONE:
(619) 715-8582
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY: CENSUS: DATE:
08/26/2025
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Randa OrahaTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On August 26, 2025, at 12:00 PM, Enforcement Analyst (EA) Adrian Mangina arrived at the address above to conduct an unannounced post licensing inspection of Bayside Respite Care LLC. Licensee was not present during designated business hours and did not return a call requesting that they return to the Home Care Organization for inspection. EA Mangina previously attempted to conduct this visit on 6/23/25 and Licensee was not present and again did not call back timely. This is the second missed visit during business hours.

Licensee is advised that additional missed visits could result in consequences including revocation of the license.

Deficiencies cited on the attached HCS809-D form and emailed to Licensee along with a copy of the HCS9058 Appeal Rights form.
NAME OF LICENSING PROGRAM ANALYST: Adrian L Mangina
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2025
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 08/26/2025 02:06 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 08/26/2025 at 01:33 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
Although this visit/inspection may have focused on the review of specific licensing requirements, the applicant/licensee must comply with all applicable requirements. The California Department of Social Services retains authority to issue citations or take disciplinary action for any deficiency.


FACILITY NAME: BAYSIDE RESPITE CARE LLC
FACILITY NUMBER: 374700357

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/27/2025
Section Cited
1796.53
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Authority to Visit HCOs : A duly authorized officer, employee, or agent of the department may, upon presentation of proper identification, enter a home care organization during posted business hours, with or without advance notice, to secure compliance with, or to prevent a violation of, any provision of this chapter or any provision promulgated under this chapter.
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This requirement was not evidenced by: EA has made two attempts to conduct a required post Licensing visit during designated business hours on 6/23/25 and today but Licensee was not present during posted business hours anddid not respond to voicemail message timely, thus EA was not able to enter premises to conduct records review, a finding which poses an immediate health and safety risk to persons in care.
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Type A
08/27/2025
Section Cited
1796.52(c)
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Inspections and Investigations; Oversight Responsibilities; Abuse Cross-Reporting: An investigation or inspection conducted by the department pursuant to this chapter may include, but is not limited to, inspection of the books, records, or premises of a home care organization. A home care organization’s refusal to make records, books, or premises available shall constitute cause for the revocation of the home care organization’s license.
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This requirement was not met as evidenced by: Licensee was not present during declared business hours on more than on occaision and has refused to return Enfocement Analyst calls while at Home Care organization during designated business hours and is thus refusing to provide records in violation of the law, return to office at request of Enforcement Analysts during today's business hours which constitutes A home care organization’s refusal to make records, books, or premises available, 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: 08/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2025
LIC809 (FAS) - (06/04)
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