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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 434700095
Report Date: 08/13/2024
Date Signed: 08/15/2024 07:25:49 AM

Document Has Been Signed on 08/15/2024 07:25 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:POLARIS HOME CARE LLCFACILITY NUMBER:
434700095
ADMINISTRATOR/
DIRECTOR:		KEMPER, GREGORYFACILITY TYPE:
300
ADDRESS:1361 S WINCHESTER BLVD STE 101TELEPHONE:
(408) 400-7020
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: CENSUS: DATE:
08/13/2024
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Gregory KemperTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Home Care Services Bureau (HCSB) analyst, Ramsey Chimienti, arrived at the business office of Polaris Home Care for a biennial inspection on 8/13/24. Upon arrival, the HCSB analyst identified himself and was greeted by Gregory Kemper. 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. Licensee indicated that additional time would be needed to obtain documents that were requested by the analyst in order to complete the inspection. Based on the Analysts observations, interviews which were conducted and partial records review, the Analyst determined that the inspection needed to be resumed at a later date. Analyst Chimienti conducted an exit interview with the Licensee and emailed a copy of the HCS 809 report.
LICENSING EVALUATOR NAME: Ramsey Chimienti
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2024
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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