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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 194700619
Report Date: 12/26/2024
Date Signed: 12/26/2024 11:56:43 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/26/2024 11:56 AM - 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:HOLLY SERVICES INCFACILITY NUMBER:
194700619
ADMINISTRATOR/
DIRECTOR:		KOSUGI, KANFACILITY TYPE:
300
ADDRESS:11100 VALLEY BLVD STE 340TELEPHONE:
(626) 333-6767
CITY:EL MONTESTATE: CAZIP CODE:
91734
CAPACITY: CENSUS: DATE:
12/26/2024
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Harumi Stoehr (Office Manager) and Yoko Kikuta (Supervisor)TIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Home Care Services Bureau Enforcement Analyst (EA) Ryan Chan arrived at the business office of Holly Services, Inc on 12/26/24 for a biennial inspection. Upon arrival, EA identified himself and was greeted by Harumi Stoehr (Office Manager) and Yoko Kikuta (Supervisor). The proper posting of business hours and license was observed. EA was then shown to an area where the review of personnel and administrative files could be performed. Upon completion of the file review EA discussed the findings of the inspection with both Harumi Stoehr and Yoko Kikuta and informed them that no discrepancies were found.

EA Chan concluded the visit with an exit interview and provided a copy of this report along with appeal rights.

LICENSING EVALUATOR NAME: Ryan Chan
LICENSING EVALUATOR SIGNATURE: DATE: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2024
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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