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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 494700034
Report Date: 09/12/2023
Date Signed: 09/12/2023 03:05:44 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/12/2023 03:05 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: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
Required - 2 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sanaila MatakibauTIME COMPLETED:
03:30 PM
NARRATIVE
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Home Care Services Bureau (HCSB) analyst Ramsey Chimienti arrived at the business office of Divine Fijian's Home Care for a biennial inspection on 9/12/23. Upon arrival, the HCSB analyst identified himself and was greeted by Sanaila Matakibau. 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. Upon completion of the file review the analyst discussed the findings of the inspection with the Sanaila. The analyst informed the Designee of the deficiencies found and explained they would be noted on the 809D.
LICENSING EVALUATOR NAME: Ramsey Chimienti
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2023
I acknowledge receipt of this form and understand my 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.

HCS809 (FAS) - (06/04)
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Document Has Been Signed on 09/12/2023 03:05 PM - It Cannot Be Edited


Created By: Ramsey Chimienti On 09/12/2023 at 02:36 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: 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.
Type A
09/22/2023
Section Cited
1796.45
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(a) 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.
Type B
10/12/2023
Section Cited
1796.42 (e)
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1796.42 (e)
A home care organization licensee shall do all of the following:
Report any suspected or known dependent adult or elder abuse as required by Section 15630 of the Welfare and Institutions Code and suspected or known child abuse as required by Sections 11164 to 11174.3, inclusive, of the Penal Code. A copy of each suspected abuse report shall be maintained and available for review by the department during normal business hours.
Type B
10/12/2023
Section Cited
1796.44
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(a) A home care organization licensee shall ensure that prior to providing home care services, an affiliated home care aide shall complete the training requirements specified in this section.
(b) An affiliated home care aide shall complete a minimum of five hours of entry-level training prior to presence with a client, as follows:
(1) Two hours of orientation training regarding his or her role as caregiver and the applicable terms of employment.
(2) Three hours of safety training, including basic safety precautions, emergency procedures, and infection control.
(c) In addition to the requirements in subdivision (b), an affiliated home care aide shall complete a minimum of five hours of annual training. The annual training shall relate to core competencies and be population specific, which shall include, but not be limited to, the following areas:
(1) Clients’ rights and safety.
(2) How to provide for and respond to a client’s daily living needs.
(3) How to report, prevent, and detect abuse and neglect.
(4) How to assist a client with personal hygiene and other home care services.
(5) If transportation services are provided, how to safely transport a client.
(d) The entry-level training and annual training described in subdivisions (b) and (c) may be completed through an online training program.
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: Ramsey Chimienti
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2023
LIC809 (FAS) - (06/04)
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