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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 494700034
Report Date: 04/26/2024
Date Signed: 04/26/2024 11:04:43 AM

Unsubstantiated


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
02/23/2024 and conducted by Evaluator Todd Borcher
PUBLIC
COMPLAINT CONTROL NUMBER: 47-HC-20240223095736
FACILITY NAME:DIVINE FIJIAN'S HOME CAREFACILITY NUMBER:
494700034
ADMINISTRATOR:KOROITAMANA, POASAFACILITY TYPE:
300
ADDRESS:3270 MENDOCINO AVETELEPHONE:
(707) 304-9179
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:CENSUS: DATE:
04/26/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee - Poasa KoroitamanaTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
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5
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7
8
9
HCO is not providing services to client as contracted.
INVESTIGATION FINDINGS:
1
2
3
4
5
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7
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9
10
11
12
13
Home Care Services Branch (HCSB) Analyst, Todd Borcher, arrived at the business address provided for Divine Fijian's Home Care, located at 3270 Mendocino Avenue, Santa Rosa, CA 95403. Analyst Borcher met with Licensee Poasa Koroitamana to discuss the above complaint allegation.

Based on the evidence obtained and interview conducted, the allegation is outside the scope of the Home Care Services Bureau’s jurisdiction, therefore is UNSUBSTANTIATED.

Analyst Borcher concluded the visit with an exit interview and provided a copy of the HCS 9099 investigation report along with appeal rights.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wendy Scott
LICENSING EVALUATOR NAME: Todd Borcher
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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