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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434700108
Report Date: 03/17/2023
Date Signed: 03/17/2023 08:45:55 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
03/30/2022 and conducted by Evaluator Ruben Perez
PUBLIC
COMPLAINT CONTROL NUMBER: 47-HC-20220330110852
FACILITY NAME:SUPREME COMPANIONSFACILITY NUMBER:
434700108
ADMINISTRATOR:CRYSTAL GAYLE GALANGFACILITY TYPE:
300
ADDRESS:830 STEWART DR. STE 221TELEPHONE:
(408) 768-5049
CITY:SUNNYVALESTATE: CAZIP CODE:
94089
CAPACITY:CENSUS: DATE:
03/17/2023
UNANNOUNCEDTIME BEGAN:
07:00 AM
MET WITH:Marlon GalangTIME COMPLETED:
11:00 PM
ALLEGATION(S):
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HCO is working unregistered caregivers and using 1099 contracts.
INVESTIGATION FINDINGS:
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On 3/17/2023, Associate Governmental Program Analysts (AGPA) Ruben Perez met with Owner, Marlon Galang of the Home Care Organization (HCO), Supreme Companions, located at 830 Stewart Dr, STE 221, Sunnyvale, CA 94089 regarding the allegation above. Marlon admitted to using 1099 contracts and understood that every caregiver needs to be a W2 employee. In addition, 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.

Based on AGPA's observations and interviews, the preponderance of evidence standard has been met,
therefore, the above allegation is found to be SUBSTANTIATED. Health and Safety Code. Article 7.
Section 1742.(b), Article 2.1796.14(b), and Article 7 1796.43(a) is being cited on the attached LIC 9099D.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wendy Scott
LICENSING EVALUATOR NAME: Ruben Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
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-20220330110852
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: SUPREME COMPANIONS
FACILITY NUMBER: 434700108
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/17/2023
Section Cited
1796.42 (b)
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All employees are required by California law to be W2 employees if working as a caregiver for a Home Care Organization.
1796.42 (b) A home care organization licensee shall do all of the following:
(b) Maintain and abide by a valid workers’ compensation policy covering its affiliated home care aides.

Marlon admitted to using 1099 contracts.
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Provide proof of conversion of all 1099 employees to W2 and send to the analyst for your HCO by 4/17/2023. Please include your payroll report and most recent DE9C tax reporting forms.
Type A
04/17/2023
Section Cited
1796.14 (b)
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1796.14 (b), 1796.43(a)

1796.14. (b) An affiliated home care aide shall be listed on the home care aide registry prior to providing home care services to a client.

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. In addition, the home care organization shall do all of the following:
(1) Ensure any staff person, volunteer, or employee of a home care organization who has contact with clients, prospective clients, or confidential client information that may pose a risk to the clients’ health and safety has met the requirements of Sections 1796.23, 1796.24, 1796.25, 1796.26, and 1796.28 before there is contact with clients or prospective clients or access to confidential client information.
(2) Require home care aides to demonstrate that they are free of active tuberculosis disease, pursuant to Section 1796.45.
(3) Immediately notify the department when the home care organization no longer employs an individual as an affiliated home care aide.

Marlon admitted to working caregivers prior to registration.
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Scan proof of clearance in the form of a screen capture from the Home Care Aide Registry Search site or a copy of your current personnel roster in Guardian showing registered/eligible for all employees and email to sheila.glover@dss.ca.gov by 4/17/2023.
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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.
SUPERVISORS NAME: Wendy Scott
LICENSING EVALUATOR NAME: Ruben Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023
LIC9099 (FAS) - (06/04)
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