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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003949
Report Date: 09/29/2021
Date Signed: 09/29/2021 05:07:29 PM

Document Has Been Signed on 09/29/2021 05:07 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
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:
09/29/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:06 PM
MET WITH:CRISINA JACKSON,TIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit. LPA met with Crisina Jackson and explained the purpose of the visit.
The purpose of the case management visit is to follow up on a learned deficiency during a complaint investigation.

The following deficiencies was discovered:

LPA toured the facility with Crisina Jackson and reviewed the facility sketch with Crisina Jackson. The facility sketch does not reflect the current resident room layout of the facility. The facility sketch states rooms 4 and 5 are designated for staff use. However, rooms 4 and 5 are currently occupied by residents. Additionally, room 9 is designated for resident use although the room 9 is being rented as room and board occupancy. Moreover, room 1 is designated for office use though it is currently being rented as a room and board occupancy. Live in staff is residing in room 8, which is designated as resident room.

As a result, the facility is not adhering to Title 22 Regulations, and deficiencies can be found on the 809-D report. An exit interview was conducted with Crisina Jackson, and a copy of this report was given to the facility at the end of this visit.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2021
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 2
Document Has Been Signed on 09/29/2021 05:07 PM - It Cannot Be Edited


Created By: Avelina Martinez On 09/29/2021 at 02:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: HOLY FAMILY HOME
FACILITY NUMBER: 347003949

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/19/2021
Section Cited
CCR
87208(a)(7)(B)

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87208(a)(7)(A) Plan of Operation: Each facility shall have and maintain a current, written definitive plan of operation...The plan and related materials shall contain the following: Sketches, showing dimensions, of the following:(B) The grounds showing buildings... recreation area and other space used by the residents.
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Crisina agrees to follow the approved facility sketch. Residen1 and Resident 2 will be transferred to a designated resident room. Tenant 1 is a current provider and will move into a designated staff room. Tenant 2 will be hired as a care staff, and will be transferring to designated staff room. Tenant 3 will be moving out within 30 days.
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This requirement was not met as evidence by: Based on observation and document review the licensee did report any room changes and did not maintain a current plan of operation by not updating facility sketch, and did not submit changes to CCLD. This posed a potential risk to residents in care.
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All staff and resident room changes will be completed by 10/19/2021. Licensee agrees to conduct weekly phone calls with LPA Martinez to discuss plan of operation and capacity.
Type B
11/19/2021
Section Cited
CCR87204(a)

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87204 (a) Limitations - Capacity and Ambulatory Status:A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time...This requirement was not met as evidence by:
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Crisina agrees to follow the approved facility sketch. Residen1 and Resident 2 will be transferred to a designated resident room. Tenant 1 is a current provider and will move into a designated staff room. Tenant 2 will be hired as a care staff, and will be transferring to designated staff room. Tenant 3 will be moving out within 30 days.
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Based on observation, file review, and interviews, the licensee did not ensure the facility was not operating beyond the conditions and limitations specified on the license. Facility is at full capacity (6), and renting room and board rooms to 3 other tenants. This posed a potential risk to residents in care.
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All staff and resident room changes will be completed by 10/19/2021. Licensee agrees to conduct weekly phone calls with LPA Martinez to discuss plan of operation and capacity.
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-Lee
LICENSING EVALUATOR NAME:Avelina Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2021


LIC809 (FAS) - (06/04)
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