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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 414700073
Report Date: 08/07/2024
Date Signed: 08/07/2024 02:47:15 PM

Document Has Been Signed on 08/07/2024 02:47 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:MY CAREGIVERS INCFACILITY NUMBER:
414700073
ADMINISTRATOR/
DIRECTOR:		MILTON EMILIO DURAN RIBERAFACILITY TYPE:
300
ADDRESS:20 PARKWOOD DRIVETELEPHONE:
(415) 573-5731
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: CENSUS: DATE:
08/07/2024
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Milton DuranTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Enforcement Analyst (EA), Ruben Perez, with the Home Care Services Branch (HCSB) conducted an onsite inspection for the purpose of a biennial visit. The EA met with licensee, Milton Duran. During the inspection, the EA observed the posting of the license and operating business hours. EA, Perez reviewed the personnel records for licensee, staff and Home Care Aides. Furthermore, EA, reviewed the HCO’s business records including training agenda, abuse reporting incidents, current designee and insurance requirements. During today’s visit, EA Perez found the HCO was in compliance and no deficiencies were cited. An exit interview was conducted, a copy of this report, staff records review report and the appeal rights were provided to the licensee, Milton.
LICENSING EVALUATOR NAME: Ruben Perez
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
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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