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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 414700089
Report Date: 06/02/2023
Date Signed: 07/17/2023 02:59:52 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/31/2022 and conducted by Evaluator Karen Ng
PUBLIC
COMPLAINT CONTROL NUMBER: 47-HC-20221031122422
FACILITY NAME:FIRSTLIGHT HOME CARE OF THE PENINSULAFACILITY NUMBER:
414700089
ADMINISTRATOR:CARTERIS, JAMESFACILITY TYPE:
300
ADDRESS:124 EL CAMINO REALTELEPHONE:
(650) 486-1310
CITY:SAN CARLOSSTATE: ZIP CODE:
94070
CAPACITY:CENSUS: DATE:
06/02/2023
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jim Carteris, LicenseeTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
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5
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8
9
A Home Care Organization (HCO) employee is falsifying and forging HCO records.
INVESTIGATION FINDINGS:
1
2
3
4
5
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7
8
9
10
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12
13
On 6/2/23 at approximately 10:15am, Home Care Services Analyst (HCSA), Karen Ng, spoke with Home Care Organization (HCO) licensee, Jim Carteris regarding the above complaint allegation.

Mr. Carteris strongly denies himself falsifying and forging of HCO statements or records and denies this occurring in his HCO or at least this issue has never been brought to his attention and will certainly include this in their code of conduct policies.

Based on the HCSA’s record review of the HCO roster and interview conducted, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, HCS 9099 and appeal rights provided by email, and licensee was told to sign and send back to Home Care Services Bureau.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Chong Vang
LICENSING EVALUATOR NAME: Karen Ng
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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