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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002950
Report Date: 09/27/2023
Date Signed: 09/27/2023 04:39:49 PM


Document Has Been Signed on 09/27/2023 04:39 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 6DATE:
09/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Joseph RussellTIME COMPLETED:
04:45 PM
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On 9/27/2023, Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived to the facility unannounced to conduct a Required 1- year annual inspection. LPAs contacted Administrator who informed LPAs she was unavailable for training but LPAs can meet with Caregiver, Joseph Russell, for assistance.

The facility is licensed for six bedridden residents, hospice waiver of six. LPAs were informed there are three residents on hospice services.

During today's inspection, LPAs and Caregiver conducted a tour of the exterior and interior of facility to ensure the health and safety of residents in care. Areas toured included but not limited to: six residents bedrooms, two bathroom, medication room, kitchen, backyard and the common areas.

LPAs observed toxins, medication and sharps to be locked and secured. Additionally, LPAs observed the pond in the backyard to be locked and inaccessible to residents in care. LPAs completed the CARE tool and found the facility to be in compliance.

At this time, LPAs requested a copy of LIC 500 and liability insurance to be emailed to LPA Yang by Friday October 6, 2023.

Exit interview and a copy of the report was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2023
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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