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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 384700020
Report Date: 02/21/2024
Date Signed: 02/21/2024 01:02:28 PM

Document Has Been Signed on 02/21/2024 01:02 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:SUPPLE SENIOR CARE, LLCFACILITY NUMBER:
384700020
ADMINISTRATOR:SUPPLE, CAITRIONAFACILITY TYPE:
300
ADDRESS:808 BURLWAY ROAD SUITE 3TELEPHONE:
(415) 573-5141
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: CENSUS: DATE:
02/21/2024
Required - 2 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Caitriona SuppleTIME COMPLETED:
01:00 PM
NARRATIVE
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Home Care Services Bureau (HCSB) analyst Ruben Perez arrived at the business office of Supple Senior Care on 2/21/2024 for a biennial inspection. Upon arrival, the HCSB analyst identified himself and was greeted by Caitriona Supple. 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. Upon completion of the file review the analyst discussed the findings of the inspection with the licensee. The analyst informed the licensee of the deficiencies found and explained they would be noted on the 809D.
LICENSING EVALUATOR NAME: Ruben Perez
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2024
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 02/21/2024 01:02 PM - It Cannot Be Edited


Created By: Ruben Perez On 02/21/2024 at 11:19 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: SUPPLE SENIOR CARE, LLC
FACILITY NUMBER: 384700020

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/01/2024
Section Cited
1796.45 (c)
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(c) After submitting to an examination, an affiliated home care aide whose test for tuberculosis infection shall be required to undergo an examination at least once every two years. Once an affiliated home care aide has a documented positive test for tuberculosis infection that has been followed by an X-ray, the examination is no longer required.
Type B
03/01/2024
Section Cited
1796.42 (e)
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A home care organization licensee shall do all of the following:
Report any suspected or known dependent adult or elder abuse as required by Section 15630 of the Welfare and Institutions Code and suspected or known child abuse as required by Sections 11164 to 11174.3, inclusive, of the Penal Code. A copy of each suspected abuse report shall be maintained and available for review by the department during normal business hours.
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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: Ruben Perez
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2024
LIC809 (FAS) - (06/04)
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