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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003949
Report Date: 05/12/2021
Date Signed: 05/12/2021 11:03:28 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:HOLY FAMILY HOMEFACILITY NUMBER:
347003949
ADMINISTRATOR:JACKSON, CRISINAFACILITY TYPE:
740
ADDRESS:1440 HOOD ROADTELEPHONE:
(916) 532-7078
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:6CENSUS: 6DATE:
05/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Chrisina JacksonTIME COMPLETED:
11:15 AM
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On 5/12/21 at 9:00am Licensing Program Analysts (LPAs) Kevin Gould and Anthony Tuck conducted an unannounced Required Annual inspection. There are 6 residents that live in the home. There is one (1) resident on hospice. The facility has a boarder that lives in the facility. The boarder has the required fingerprints and TB test.

LPAs inspected the physical plant to ensure the health and safety of the residents in care. LPA inspected the facility, including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room, backyard and garage. The facility had the required carbon monoxide detectors. LPA observed the facility to be free of odor and clean. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. There are no bodies of water present in the facility at this time. LPA observed sufficient seven day non-perishable and two day perishable food supplies. LPAs observed a torn screen door on bedroom # 8 that requires repair and a broken porch swing no longer in use in the back yard that LPAs request be removed.

Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications and toxins are kept locked and inaccessible to clients. First aid kit was checked and is complete. Hot water was tested and measured at 118 degree F. which is within the required range of 105-120*F.

Based on today’s visit, Per California Code of Regulations, Title 22 Division 6, Chapter 8, the following deficiencies are cited. Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: HOLY FAMILY HOME
FACILITY NUMBER: 347003949
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation a torn sliding sceen door on bedroom #8 which poses a potential safety risk to persons in care.
POC Due Date: 05/17/2021
Plan of Correction
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Administrator agreed to repair screen by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2021
LIC809 (FAS) - (06/04)
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