<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343617929
Report Date: 07/22/2021
Date Signed: 07/22/2021 10:54:36 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:HOLUB, JANETFACILITY NUMBER:
343617929
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 7DATE:
07/22/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Janet HolubTIME COMPLETED:
09:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At 9:15 a.m. on Thursday, July 22nd, 2021, Licensing Program Analyst (LPA) Karyn Guerra met with Licensee, Janet Holub for the purpose of a case management inspection. A COVID-19 risk assessment was conducted via telephone prior to entering the facility. Licensee requests to make previously off limits guest room an on limits space. Licensee gave a tour of the room. LPA did not see any hazards. As of today, the room is considered on-limits.Licensee provided an updated Facility Sketch form LIC999 to reflect new on limits area. Licensee understands that an inspection must be conducted prior to making any off limits space of the home an on limits space. This report was reviewed with the Licensee. Notice of Site Visit was provided and shall be posted for 30 days. In the areas that were evaluated, no deficiencies were observed during today's inspection.
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1