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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434700108
Report Date: 05/15/2024
Date Signed: 05/15/2024 09:46:06 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
04/23/2024 and conducted by Evaluator Ramsey Chimienti
COMPLAINT CONTROL NUMBER: 47-HC-20240423080849
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:
94085
CAPACITY:CENSUS: DATE:
05/15/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Marlon GalangTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Home Care Aides are not registered on the Home Care Aide Registry prior to caring for clients.
INVESTIGATION FINDINGS:
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Home Care Services Branch (HCSB) Analyst, Ramsey Chimienti, completed a follow-up complaint investigation via phone/email regarding the above allegation. Analyst Chimienti spoke to Licensee, Marlon Galang. The analyst explained that he was finalizing a complaint investigation regarding the above complaint.
The analysts reviewed a list of documents that were previously made available by Mr. Galang in order to complete the investigation. The requested documents included payroll, previous two Quarterly DE9 tax reports submitted by the company, last six weeks of payroll reports, a list of all W2 employees.
Based on Analyst’s observations and interviews, 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, Section 1796.43(a) is being cited on the attached LIC 9099D.
Analyst Chimienti concluded the visit with an exit interview via phone 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: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
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-20240423080849
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: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/16/2024
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 copy of the personnel roster from Guardian showing “Eligible-Clearance” must be documented for all caregivers prior to contact with clients.
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was not documented for one of the 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 Sheila.Glover@dss.ca.gov by 5/16/2024.
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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: Ramsey Chimienti
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2