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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 414700136
Report Date: 09/16/2025
Date Signed: 09/17/2025 08:53:56 AM

Document Has Been Signed on 09/17/2025 08:53 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:GOLDEN HEART CARE PROVIDERSFACILITY NUMBER:
414700136
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, MARIA JESUSAFACILITY TYPE:
300
ADDRESS:884 CARINA LANETELEPHONE:
(650) 815-5028
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY: CENSUS: DATE:
09/16/2025
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Susan HernandezTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Home Care Services Bureau (HCSB) analyst, Ruben Perez, arrived at the business office of Golden Heart Care Providers for an initial inspection on 9/16/2025. Upon arrival, the HCSB analyst identified himself and was greeted by Susan Hernandez. 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 Susan of the deficiencies found and explained they would be noted on the 809D.
NAME OF LICENSING PROGRAM ANALYST: Ruben Perez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2025
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 09/17/2025 08:53 AM - It Cannot Be Edited


Created By: Ruben Perez On 09/16/2025 at 12:53 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
Although this visit/inspection may have focused on the review of specific licensing requirements, the applicant/licensee must comply with all applicable requirements. The California Department of Social Services retains authority to issue citations or take disciplinary action for any deficiency.


FACILITY NAME: GOLDEN HEART CARE PROVIDERS
FACILITY NUMBER: 414700136

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2025
Section Cited
1796.43 (a)
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Health and Safety Code § 1796.43 (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. Proof of clearance on the Home Care Aide Registry was not documented in multiple of the caregiver’s personnel records that were reviewed by HCSB analyst. This poses an immediate health and safety risk to clients in care.
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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: 09/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2025
LIC809 (FAS) - (06/04)
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