<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 434700177
Report Date: 09/20/2023
Date Signed: 09/26/2023 03:20:55 PM

Document Has Been Signed on 09/26/2023 03:20 PM - 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:GLORIOUS HOME CARE ASSISTANCE LLCFACILITY NUMBER:
434700177
ADMINISTRATOR:AMUNGWA, MINILVA SIRRIFACILITY TYPE:
300
ADDRESS:111 N MARKET ST STE 300TELEPHONE:
6692958659
CITY:SAN JOSESTATE: CAZIP CODE:
95113
CAPACITY: CENSUS: DATE:
09/20/2023
Post LicensingUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Minilva AmungwaTIME COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Home Care Services Bureau (HCSB) Associate Government Program Analyst (AGPA) Megan Vigil, arrived at the business office of Glorious Home Care Assistance LLC on 9.20.23 at approximately 3:20pm. Upon arrival, AGPA Vigil identified herself and was greeted by Licensee Minilva Amungwa. 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. The proof of insurance's record was reviewed. Upon completion of the file review the analyst discussed the findings of the inspection with Licensee. The analyst informed the deficiencies found and explained they would be noted on the 809D.
LICENSING EVALUATOR NAME: Megan Vigil
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 09/26/2023 03:20 PM - It Cannot Be Edited


Created By: Megan Vigil On 09/20/2023 at 04:45 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

FACILITY NAME: GLORIOUS HOME CARE ASSISTANCE LLC
FACILITY NUMBER: 434700177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2023
Section Cited
1796.42 (e)
1
2
3
4
5
6
7
1796.42 (e) A home care organization licensee shall do all of the following:
Report any suspected or known dependent adult or elder abuse .. A copy of each suspected abuse report shall be maintained and available for review by the department during normal business hours.
8
9
10
11
12
13
14
Owner does not have clients or caregivers yet but needs to complete the employee files. This poses a potential Health and Safety risk to person in care.
8
9
10
11
12
13
14
Type B
10/27/2023
Section Cited
1796.23 (a)
1
2
3
4
5
6
7
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.
8
9
10
11
12
13
14
Owner should make sure all employees and caregivers have proof of clearance. This poses a potential Health and Safety risk to person in care..
8
9
10
11
12
13
14
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: Megan Vigil
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2