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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 414700057
Report Date: 05/02/2024
Date Signed: 05/02/2024 10:05:28 AM

Document Has Been Signed on 05/02/2024 10:05 AM - 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:FAMILY AFFAIR HOME CAREFACILITY NUMBER:
414700057
ADMINISTRATOR/
DIRECTOR:		HUI LESLIEFACILITY TYPE:
300
ADDRESS:3100 COLLEGE DRIVETELEPHONE:
(415) 672-1599
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: CENSUS: DATE:
05/02/2024
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Xuefei HuangTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
NARRATIVE
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Home Care Services Bureau (HCSB) analyst Ruben Perez arrived at the business office of Family Affair Home Care on 5/2/2024 for an initial inspection. Upon arrival, the HCSB analyst identified himself and was greeted by Xuefei Huang. 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 designee. The analyst informed the designee of the deficiencies found and explained they would be noted on the 809D.
LICENSING EVALUATOR NAME: Ruben Perez
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 05/02/2024 10:05 AM - It Cannot Be Edited


Created By: Ruben Perez On 05/02/2024 at 09:54 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: FAMILY AFFAIR HOME CARE
FACILITY NUMBER: 414700057

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2024
Section Cited
1796.42
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(e) 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.
Type A
05/10/2024
Section Cited
1796.43
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(a) “Home care organizations that employ affiliated home care aides shall ensure the affiliated home care aides are cleared on the home care aide registry before placing the individual in direct contact with clients...”
Type A
05/10/2024
Section Cited
1796.45
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(d) After each examination, an affiliated home care aide shall submit, and the home care organization shall keep on file, a certificate from the examining practitioner showing that the affiliated home care aide was examined and found free from active tuberculosis disease.
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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: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
LIC809 (FAS) - (06/04)
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