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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 374700359
Report Date: 07/22/2024
Date Signed: 07/22/2024 05:37:36 PM

Document Has Been Signed on 07/22/2024 05:37 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:HOME INSTEADFACILITY NUMBER:
374700359
ADMINISTRATOR/
DIRECTOR:		SYMPHONY KRUEGERFACILITY TYPE:
300
ADDRESS:5360 JACKSON DR. #120TELEPHONE:
(916) 878-0360
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY: CENSUS: DATE:
07/22/2024
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Symphony KruegerTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Home Care Services Bureau (HCSB) Analyst, Adrian Mangina arrived at the business office of Home Instead on July 22, 2024 for a post licensing inspection. Upon arrival, Analyst Mangina Upon arrival, the t identified herself and was greeted by Designee Dawn Burns. Designee Maria Martinez was also present. Licensee Symphony Krueger arrived a short time later. The proper posting of business hours and license was observed. The Analyst was shown to an area where the review of personnel and administrative files could be performed. Analyst observed current insurance policies and dishonesty bond and complete Home Care Aide files. Upon completion of the file review the analyst discussed the findings of the inspection with Licensee and informed the Licensee that no discrepancies were found.
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2024
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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