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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 544700006
Report Date: 11/01/2023
Date Signed: 11/01/2023 03:15:24 PM

Document Has Been Signed on 11/01/2023 03:15 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:EXTRA CARING HOMECARE LLCFACILITY NUMBER:
544700006
ADMINISTRATOR:SHIRLEE COXFACILITY TYPE:
300
ADDRESS:4119 W WALNUT AVENUETELEPHONE:
(559) 469-1125
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: CENSUS: DATE:
11/01/2023
Required - 2 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Shirlee CoxTIME COMPLETED:
02:30 PM
NARRATIVE
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Home Care Services Bureau (HCSB) analyst Ruben Perez arrived at the business office of Extra Caring Homecare LLC on 11/1/2023 for a biennial inspection. Upon arrival, the HCSB analyst identified himself and was greeted by Shirlee Cox. 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 designee. The analyst informed the designee of the deficiencies found and explained they would be noted on the 809D.
LICENSING EVALUATOR NAME: Ruben Perez
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023
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 11/01/2023 03:15 PM - It Cannot Be Edited


Created By: Ruben Perez On 11/01/2023 at 12:53 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: EXTRA CARING HOMECARE LLC
FACILITY NUMBER: 544700006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/15/2023
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.
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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: Ruben Perez
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023
LIC809 (FAS) - (06/04)
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