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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 414700092
Report Date: 02/09/2022
Date Signed: 02/09/2022 01:26:18 PM

Document Has Been Signed on 02/09/2022 01:26 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
CCLD Regional Office, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:RELIEF HOME CARE, INC.FACILITY NUMBER:
414700092
ADMINISTRATOR:CHUA, JIMMYFACILITY TYPE:
300
ADDRESS:171 SCHOOL STREET, STE. BTELEPHONE:
(650) 608-0085
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY: 0CENSUS: DATE:
02/09/2022
Case Management - Biennial Required ContinuationUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Jimmy ChuaTIME COMPLETED:
02:00 PM
NARRATIVE
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Home Care Services Bureau (HCSB) Analyst, Ramsey Chimienti arrived at the business office of RELIEF HOME CARE, INC. on 2/9/2022. Upon arrival, the HCSB analyst identified himself and was greeted by Jimmy Chua. 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 Jimmy. The analyst informed him of the deficiencies found and explained they would be noted on the HCS 809D.
LICENSING EVALUATOR NAME: Ramsey Chimienti
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2022
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 02/09/2022 01:26 PM - It Cannot Be Edited


Created By: Ramsey Chimienti On 02/09/2022 at 01:19 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: RELIEF HOME CARE, INC.
FACILITY NUMBER: 414700092

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2022
Section Cited
1796.37 (a)
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1796.37 (a)(2)(12)
(a) A home care organization that has its principal place of business in another state, in addition to the other requirements of this chapter, before arranging for home care services provided by an affiliated home care aide to a client in the state, shall comply with all of the following:
(2) Maintain all pertinent records of the operation in California at the California office. All records shall be available to review, copy, audit, and inspect by the licensing agency.
(12) Provides any other information as may be required by the department for the proper administration and enforcement of this chapter.
Type B
03/17/2022
Section Cited
1796.23 (a)
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1796.23 (a)
(a) Each person initiating a background examination to be a registered home care aide shall submit his or her fingerprints to the Department of Justice by electronic transmission in a manner approved by the State Department of Social Services, unless exempt under subdivision (d). Each person initiating a background examination to be a registered home care aide shall also submit to the State Department of Social Services a signed declaration under penalty of perjury regarding any prior criminal convictions pursuant to Section 1522 and a completed home care aide application.
Type B
03/17/2022
Section Cited
1796.42(a)
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1796.42(a)(1), 1796.23
(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. In addition, the home care organization shall do all of the following:
(1) Ensure any staff person, volunteer, or employee of a home care organization who has contact with clients, prospective clients, or confidential client information that may pose a risk to the clients’ health and safety has met the requirements of Section 1796.23 before being hired.
1796.23
(a) Each person initiating a background examination to be a registered home care aide shall submit his or her fingerprints to the Department of Justice by electronic transmission in a manner approved by the State Department of Social Services, unless exempt under subdivision (d). Each person initiating a background examination to be a registered home care aide shall also submit to the State Department of Social Services a signed declaration under penalty of perjury regarding any prior criminal convictions pursuant to Section 1522 and a completed home care aide application.
Type B
02/17/2022
Section Cited
1796.23
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1796.23
(a) Each person initiating a background examination to be a registered home care aide shall submit his or her fingerprints to the Department of Justice by electronic transmission in a manner approved by the State Department of Social Services, unless exempt under subdivision (d). Each person initiating a background examination to be a registered home care aide shall also submit to the State Department of Social Services a signed declaration under penalty of perjury regarding any prior criminal convictions pursuant to Section 1522 and a completed home care aide application.
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: Ramsey Chimienti
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2022
LIC809 (FAS) - (06/04)
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