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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 424700034
Report Date: 03/14/2024
Date Signed: 04/17/2024 12:15:02 PM

Document Has Been Signed on 04/17/2024 12:15 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:SUPERIOR SENIOR HOME CAREFACILITY NUMBER:
424700034
ADMINISTRATOR:MARTINEZ, PABLOFACILITY TYPE:
300
ADDRESS:320 E WALNUT AVETELEPHONE:
(805) 737-4357
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY: CENSUS: DATE:
03/14/2024
Annual/RandomUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Pablo MartinezTIME COMPLETED:
03:15 PM
NARRATIVE
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Home Care Services Bureau (HCSB) analyst, Ramsey Chimienti, arrived at the business office of Superior Senior Home Care for an initial inspection on 3/14/24. Upon arrival, the HCSB analyst identified himself and was greeted by Pablo Martinez. 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 the Licensee of the deficiencies found and explained they would be noted on the 809D.
LICENSING EVALUATOR NAME: Ramsey Chimienti
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2024
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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Document Has Been Signed on 04/17/2024 12:15 PM - It Cannot Be Edited


Created By: Ramsey Chimienti On 03/19/2024 at 10:17 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: SUPERIOR SENIOR HOME CARE
FACILITY NUMBER: 424700034

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/26/2024
Section Cited
1796.45 (a)
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Health and Safety Code § 1796.45 (a) Affiliated home care aides hired on or after January 1, 2016, shall submit to an examination 90 days prior to employment, or within seven days after employment, to determine that the individual is free of active tuberculosis disease. TB clearance was not documented in the caregiver’s personnel records that were reviewed by HCSB analyst. This poses an immediate health and safety risk to clients in care.
Type B
04/15/2024
Section Cited
1796.44 (a)
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Health and Safety Code § 1796.44 (a) A home care organization licensee shall ensure that prior to providing home care services, an affiliated home care aide shall complete the training requirements specified in this section.
A record of completion of the required training hours and topics was not documented in the caregiver’s personnel records that were reviewed by HCSB analyst. This poses a potential 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: Ramsey Chimienti
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2024
LIC809 (FAS) - (06/04)
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