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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200795
Report Date: 05/04/2022
Date Signed: 05/04/2022 06:10:00 PM


Document Has Been Signed on 05/04/2022 06:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:HOLISTIC CARE HOMEFACILITY NUMBER:
019200795
ADMINISTRATOR:NGUYEN, AYWON-ANHFACILITY TYPE:
740
ADDRESS:14724 PEPPERDINE STTELEPHONE:
(510) 969-7966
CITY:SAN LEANDROSTATE: CAZIP CODE:
94579
CAPACITY:6CENSUS: 6DATE:
05/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Christopher Martinez, Care Staff TIME COMPLETED:
06:15 PM
NARRATIVE
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On 05/04/22 at 3:05 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct Infection Control Inspection. LPA met with staff Christopher Martinez and explained the purpose of the visit. The facility is in the process of changing owner/license/administrator. Several staff present at the facility, Diana Sibayo and Bonfacio Del Mundo, are not fingerprinted or associated to the facility.

During the Infection Control Inspection, LPA toured facility including but not limited to: front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPE maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

A civil penalty for uncleared staff is being assessed in the amount of $600.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/04/2022 06:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: HOLISTIC CARE HOME
FACILITY NUMBER: 019200795

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2022
Section Cited

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Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to California Code of Regulations Section 7355(e)1 shall prior to working, residing or volunteering in a licensed facility: This requirement was not meet as evidenced by:
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Based on record review S1 and S2 were not fingerprint cleared or associated to the facility S1 has worked at the facility since December 2021 and S2 was present at the facility today which poses an immediate heath and safety risk to persons in care.
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An immediate civil penalty of $600 is being assessed on this date (see LIC421BG).

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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.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
LIC809 (FAS) - (06/04)
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