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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 434700141
Report Date: 06/02/2026
Date Signed: 06/03/2026 09:20:06 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/03/2026 09:20 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:SYNERGY HOMECARE OF CAMPBELL/LOS GATOSFACILITY NUMBER:
434700141
ADMINISTRATOR/
DIRECTOR:		NELSON, NANETTEFACILITY TYPE:
300
ADDRESS:2006 WINCHESTER BLVD. STE DTELEPHONE:
(408) 910-2630
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: CENSUS: DATE:
06/02/2026
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Tom NelsonTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Enforcement Analyst (EA) Yolanda Hankerson met with the licensee Tom Nelson. During the visit, 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.
The Home Care Organization (HCO) was found not to be in compliance with applicable sections of the Health and Safety Code (HSC). Deficiencies were cited and documented on the 809D Correction Report. The deficiencies were discussed with the licensee Mr. Nelson at the time of the visit.
An exit interview was conducted, and copies of the 809 Facility Evaluation, 809 Deficiencies, 859 Staff Records Review Reports, and appeal rights information were provided via email.
NAME OF LICENSING PROGRAM ANALYST: Yolanda Hankerson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2026
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 06/03/2026 09:20 AM - It Cannot Be Edited


Created By: Yolanda Hankerson On 06/02/2026 at 02:46 PM
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: SYNERGY HOMECARE OF CAMPBELL/LOS GATOS
FACILITY NUMBER: 434700141

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/12/2026
Section Cited
1796.45 (a)
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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.
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TB clearance was not documented in #2 of the caregiver’s personnel records that were reviewed by HCSB analyst. This poses an immediate health and safety risk to clients in care.
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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.
LICENSING EVALUATOR NAME: Yolanda Hankerson
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2026
LIC809 (FAS) - (06/04)
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