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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 434700062
Report Date: 06/12/2026
Date Signed: 06/16/2026 10:44:49 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/16/2026 10:44 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:KIWI ASSOCIATES INC. DBA A1CAREFACILITY NUMBER:
434700062
ADMINISTRATOR/
DIRECTOR:		TUPOU SYDDALLFACILITY TYPE:
300
ADDRESS:5645 SILVER CRK VLY RD STE 201TELEPHONE:
(408) 995-3300
CITY:SAN JOSESTATE: CAZIP CODE:
95138
CAPACITY: CENSUS: DATE:
06/12/2026
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Kersha MataitiTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Enforcement Analyst (EA) Ramsey Chimienti conducted a virtual visit for the purpose of completing the required two-year visit and met with the Designee, Kersha Mataiti.
During the visit, the EA verified the posting of the license, observed the operation of the business, confirmed compliance with insurance requirements, and completed the required personnel file review. All requested documentation was provided and reviewed.
Upon completion of the file review the analyst discussed the findings of the inspection with the Licensee. The analyst informed Kersha of the deficiencies found and explained they would be noted on the 809D.
NAME OF LICENSING PROGRAM ANALYST: Ramsey Chimienti
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2026
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 06/16/2026 10:44 AM - It Cannot Be Edited


Created By: Ramsey Chimienti On 06/15/2026 at 10:24 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
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: KIWI ASSOCIATES INC. DBA A1CARE
FACILITY NUMBER: 434700062

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/19/2026
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...
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...documented in personnel records for person(s) R01, R02, R04, R05 and R06. This poses an immediate health and safety risk to clients in care.
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Type A
06/19/2026
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 personnel records for caregivers R01 and R05 that were reviewed by HCSB analyst. This poses an immediate health and safety risk to clients in care.
Type B
07/13/2026
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 personnel records for person(s) R01 through R06. This poses a potential health and safety risk to clients in care.
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: 06/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2026
LIC809 (FAS) - (06/04)
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