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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000440
Report Date: 01/21/2022
Date Signed: 01/21/2022 02:59:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:GINA'S HOME CAREFACILITY NUMBER:
347000440
ADMINISTRATOR:POP, VIRGINIAFACILITY TYPE:
740
ADDRESS:3734 HOLLISTER AVE.TELEPHONE:
(916) 944-8163
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 0DATE:
01/21/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Virginia PopTIME COMPLETED:
02:45 PM
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On 1/21/22, Licensing Program Analyst, Kevin Mknelly conducted an office visit by phone with Licensee, Virginia Pop.

The purpose of the meeting was to discuss the current change of ownership arrangements for the facility.

LPA Mknelly attempted to conduct an annual inspection on 12/15/21. the home was vacant except for some builders doing renovations. No residents are currently living at the facility.

Subsequently, the Department learned that the licensee has sold the property and the buyer plans to apply for a license.

LPA advised the licensee to complete the following:
Licensee will establish a lease agreement with the property owner in order to re-establish control of property;

Licensee plans to hire a new Administrator, Jessica Kong to oversee the home so that new residents may be admitted. Licensee will submit a designation letter, verification of certification (certificate or screen shot of active administrators CCL list), and application/ resume or CV establishing qualifications;

Prior to admitting new residents, licensee will inform CCL that renovations are complete and mitigation measures are in place so that an inspection may be conducted.

As a result of this meeting, no deficiencies are noted.

As the meeting was by phone, LPA forwarded a copy to the Licensee for review and signature.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
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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