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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002950
Report Date: 11/18/2022
Date Signed: 11/18/2022 01:16:20 PM


Document Has Been Signed on 11/18/2022 01:16 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:HOLLISTER CARE HOMEFACILITY NUMBER:
345002950
ADMINISTRATOR:KONG, JESSICAFACILITY TYPE:
740
ADDRESS:3734 HOLLISTER AVETELEPHONE:
(916) 860-3014
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 0DATE:
11/18/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jessica KongTIME COMPLETED:
01:15 PM
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On 11/18/2022, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility announced to conduct a Pre-Licensing inspection. LPA met with Administrator, Jessica Kong, and explained the purpose of the visit. Prior to today's inspection, LPA completed the required COVID-19 testing protocols to confirm no symptoms of COVID-19 infection.

LPA and Administrator toured the interior and exterior of the facility. In areas toured included but not limited to: common areas, (2) kitchens, (4) bathrooms, (6) private resident rooms, (1) caregiver room, (4) private area rooms, garage and the backyard. In areas toured, no immediate health, safety or personal rights violation were observed. LPA observed both kitchen to have a locked and secured area for sharps and toxics.

LPA observed the facility to have a designated medication cabinet. LPA observed the laundry room to be located in the garage, LPA advised Administrator that although it is locked and secure, laundry room should always have a clear pathway. LPA observed the exterior to have a clear pathway, and pool gate to be locked and secured. LPA reminded Administrator of the Immediate $500 civil penalty if pool was left accessible to residents in care. LPA advised Administrator to install lock doorknobs to rooms that are located in the private areas as residents in care may have dementia and can wander.

LPA and Administrator completed the Comp III together. At this time, no deficiencies were observed.

Exit interview conducted and a copy of the report was left at the facility.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022
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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