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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 374700378
Report Date: 02/14/2025
Date Signed: 02/14/2025 12:52:22 PM

Document Has Been Signed on 02/14/2025 12:52 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:EUCALYPTUS HOME CARE LLCFACILITY NUMBER:
374700378
ADMINISTRATOR/
DIRECTOR:		JAMES DICKSONFACILITY TYPE:
300
ADDRESS:16950 VIA DE SANTA FE, STE 132TELEPHONE:
(858) 472-5912
CITY:RANCHO SANTA FESTATE: CAZIP CODE:
92067
CAPACITY: CENSUS: DATE:
02/14/2025
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:James DicksonTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On February 14, 2025, Home Care Services Bureau (HCSB) Enforcement Analyst (EA), Adrian Mangina arrived at the business office of Eucalyptus Home Care LLC for a Biennial inspection. Upon arrival, the Enforcement Analyst identified herself to the receptionist of the shared office space. Designee James Dickson was not present but arrived approximately shortly and granted EA entry into the business office. 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. Ten employee files were reviewed.

Upon completion of the file review the analyst discussed the findings of the inspection with Designee Dickson. The Analyst informed the representative named above of the deficiency found and explained they would be noted on the HCS809-D form. In addition, the Mr. Dickson was provided a copy of the HCS9058 Appeal Rights form.

LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2025
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 02/14/2025 12:52 PM - It Cannot Be Edited


Created By: Adrian L Mangina On 02/14/2025 at 12:27 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: EUCALYPTUS HOME CARE LLC
FACILITY NUMBER: 374700378

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/15/2025
Section Cited
1796.44(b)(2)
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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...(2) Three hours of safety training, including basic safety precautions, emergency procedures, and infection control..
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This requirement was not met as evidenced by: during the review of files Licensee could not provide proof of completion of three hours ofrequired entry-level training including basic safety precautions, emergency procedures, and infection control for reference #8 and #10 at time of inspection, 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: 02/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2025
LIC809 (FAS) - (06/04)
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