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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434700095
Report Date: 10/17/2024
Date Signed: 11/05/2024 08:08:04 AM

Substantiated


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
07/24/2024 and conducted by Evaluator Ramsey Chimienti
PUBLIC
COMPLAINT CONTROL NUMBER: 47-HC-20240724085000
FACILITY NAME:POLARIS HOME CARE LLCFACILITY NUMBER:
434700095
ADMINISTRATOR:KEMPER, GREGORYFACILITY TYPE:
300
ADDRESS:1361 S WINCHESTER BLVD STE 101TELEPHONE:
(408) 400-7020
CITY:SAN JOSESTATE: ZIP CODE:
95128
CAPACITY:CENSUS: DATE:
10/17/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Greg KemperTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Home Care Aides are not approved on the Home Care Aide Registry prior to caring for clients.

Home Care Aides do not have a fingerprint clearance or exemption prior to caring for clients.
INVESTIGATION FINDINGS:
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Home Care Services Branch (HCSB) Analyst, Ramsey Chimienti, conducted a follow-up visit via phone/email with Licensee, Gregory Kemper, for the purpose of completing a complaint investigation regarding the above allegations. In the course of the investigation, the analysts reviewed a list of documents that were compiled by Mr. Kemper. The requested documents included personnel documents, payroll and quarterly DE9 tax reporting statements spanning several years.
The 2023 documents that were provided from the licensee demonstrated multiple individuals who worked shifts without being registered on the Home Care Aide Registry and/or working without fingerprint clearance from the Department. Based on Analyst’s observations, interview, and evidence collected, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. Health and Safety Code, Division 2, Chapter 13, Article 7, Sections 1796.43(a) and 1796.23 (a) are being cited on the attached HCS 9099D report.
Analyst Chimienti concluded the phone visit with an exit interview and provided a copy of the HCS 9099 and 9099D investigation reports along with appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wendy Scott
LICENSING EVALUATOR NAME: Ramsey Chimienti
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 47-HC-20240724085000
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME: POLARIS HOME CARE LLC
FACILITY NUMBER: 434700095
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2024
Section Cited
1796.23 (a)
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Health and Safety Code § 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 department, unless exempt under subdivision (d). Criminal...
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The licensee acknowledges that fingerprint clearance from the Department in the form of either a screen capture from the Home Care Aide Registry Search site, a copy of the registration/exemption approval letter from the Department, or a copy of the personnel roster from Guardian showing...
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Background Clearance and/or Exemption approval was not obtained for multiple caregivers on staff. This poses an immediate health and safety risk to clients in care.
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“Eligible-Clearance” must be documented for all caregivers prior to contact with clients in order to satisfy this requirement. The licensee will produce a typed acknowledgement of this requirement and email to Misael.Chavarin@dss.ca.gov by 10/25/2024.
Type B
10/25/2024
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...
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The licensee acknowledges that proof of clearance and registration in the form of a screen capture from the Home Care Aide Registry Search site or a registration/exemption approval letter from the Department must be kept on file for all caregivers prior to contact with clients...
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was not obtained for several, previously employed caregivers who worked shifts with client(s). This poses an immediate health and safety risk to clients in care.
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The licensee will produce a typed acknowledgement of this requirement and email to Misael.Chavarin@dss.ca.gov by 10/25/2024. Additionally, all current caregivers without registration clearance must be immediately removed from shifts with clients until proof of clearance is provided to the Department.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Wendy Scott
LICENSING EVALUATOR NAME: Ramsey Chimienti
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2