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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 564700025
Report Date: 08/08/2023
Date Signed: 08/08/2023 04:57:00 PM

Document Has Been Signed on 08/08/2023 04:57 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:MAXIM HEALTHCARE SERVICES, INC.FACILITY NUMBER:
564700025
ADMINISTRATOR:DAVID KOWALCZYKFACILITY TYPE:
300
ADDRESS:500 ESPLANADE DR., SUITE 660TELEPHONE:
(805) 981-2539
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY: CENSUS: DATE:
08/08/2023
Case Management - Biennial Required ContinuationUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Paola VillagomezTIME COMPLETED:
05:00 PM
NARRATIVE
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Home Care Services Bureau (HCSB) Associate Government Program Analyst (AGPA) Megan Vigil, arrived at the business office of Maxim Healthcare Services on 8/8/2023 at approximately 2:30 pm. Upon arrival, AGPA Vigil identified herself and was greeted by Designee, Paola Villagomez. 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 the Designee, Paola Villagomez. The analyst informed the Designee, Paola Villagomez of the deficiencies found and explained they would be noted on the 809D.
LICENSING EVALUATOR NAME: Megan Vigil
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2023
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 08/08/2023 04:57 PM - It Cannot Be Edited


Created By: Megan Vigil On 08/08/2023 at 04:46 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: MAXIM HEALTHCARE SERVICES, INC.
FACILITY NUMBER: 564700025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/08/2023
Section Cited
1796.23 (a)
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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
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Home Care Organization employed caregivers without the Home Care Aide Registry background clearance. This poses an immediate Health and Safety risk to persons in care.
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Type A
09/08/2023
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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Home Care Organization employed caregivers without the background clearance. This poses an immediate Health and Safety risk to persons in care.
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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: Megan Vigil
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2023
LIC809 (FAS) - (06/04)
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