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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 564700090
Report Date: 04/09/2024
Date Signed: 04/09/2024 12:44:29 PM

Document Has Been Signed on 04/09/2024 12:44 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 AGAPE HEALTH CARE AGENCYFACILITY NUMBER:
564700090
ADMINISTRATOR/
DIRECTOR:		DOMINGO, ARNOLDFACILITY TYPE:
300
ADDRESS:300 EAST ESPLANADE DR,9TH FLTELEPHONE:
(805) 980-8021
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY: CENSUS: DATE:
04/09/2024
Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Laura Martinez, ManagerTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Home Care Services Bureau (HCSB) Analyst, Mila Quinto arrived at the business office on 4/9/2024 for a post licensing inspection. Upon arrival, Analyst Quinto was greeted by Designee, Laura Martinez. The proper posting of business hours and license was observed. The proof of insurance's record was reviewed. 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: Mila Quinto
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
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 04/09/2024 12:44 PM - It Cannot Be Edited


Created By: Mila Quinto On 04/09/2024 at 12:03 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 AGAPE HEALTH CARE AGENCY
FACILITY NUMBER: 564700090

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/23/2024
Section Cited
1796.45(a)
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1796.45 TB Testing (a) Affiliated home care aides hired... shall submit...
This requirement is not met as evidenced by:
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Based on file review, a staff member did not have TB test result available for review.
This poses a potential health risk to people in care.
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Type B
04/23/2024
Section Cited
1796.42(e)
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1796.42 License Posting, Insurance, and Abuse Reporting
(e) .. A copy of each suspected abuse report shall be maintained and available for review by the department during normal business hours.
This requirement is not met as evidenced by:
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Based on file review, 4 of 10 HCA files did not have HCS 341A with HCA's signature.
This poses a potential safety risk to people 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: Mila Quinto
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
LIC809 (FAS) - (06/04)
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