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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 494700034
Report Date: 09/12/2023
Date Signed: 09/12/2023 03:07:39 PM

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
08/07/2023 and conducted by Evaluator Ramsey Chimienti
PUBLIC
COMPLAINT CONTROL NUMBER: 47-HC-20230807081508
FACILITY NAME:DIVINE FIJIAN'S HOME CAREFACILITY NUMBER:
494700034
ADMINISTRATOR:KOROITAMANA, POASAFACILITY TYPE:
300
ADDRESS:4927 SONOMA HWY SUITE D-1TELEPHONE:
(707) 304-9179
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:CENSUS: DATE:
09/12/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sanaila MatakibauTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Home Care Organization (HCO) has unregistered Home Care Aides (HCA) working in close contact with clients.
INVESTIGATION FINDINGS:
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On 9/12/23, Analyst Ramsey Chimienti arrived at the business address for Divine Fijian’s Home Care. Analyst Chimienti introduced himself and was greeted by Sanaila Matakibau. Analyst explained that he was there to investigate the above complaint allegation. Analyst Chimienti interviewed Mr. Matakibau regarding the company’s onboarding process for caregivers including background check and registration on the Home Care Aide (HCA) Registry. Analyst Chimienti also reviewed personnel files and payroll to ensure licensing requirements are met. The documentation demonstrated that certain HCA staff are working prior to clearance on the Home Care Aide Registry.

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 and provided a copy of the HCS 9099 investigation report along with appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wendy Scott
LICENSING EVALUATOR NAME: Ramsey Chimienti
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
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-20230807081508
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: DIVINE FIJIAN'S HOME CARE
FACILITY NUMBER: 494700034
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/26/2023
Section Cited
1796.43
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Health and Safety Code § 1796.43 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. Certain caregivers did not have a clearance on the Home Care Aide registry. This poses an immediate health and safety risk to clients in care.
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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 Eligible-Clearance for all caregivers and email to Marisa.Bodine@dss.ca.gov by 9/26/2023. Until proof of clearance and registration is provided, these caregivers must be immediately removed from shifts with clients.
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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: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2