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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003949
Report Date: 02/07/2022
Date Signed: 02/07/2022 03:40:43 PM

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: 5DATE:
02/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Anita OrenseTIME COMPLETED:
03:45 PM
NARRATIVE
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On 2/7/22 at 12:50 PM Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced case management inspection. LPA conducted a risk assessment call prior to entry verifying there were no active covid cases. LPA met with caretaker Anita Orense and stated the purpose of this inspection.

On 2/1/22 Resident 1 (R1) AWOL'd from the facility. On R1's LIC602 it states resident is unable to leave the facility unassisted. R1 doesn't recall how he/she left the facility, and staff do not know either. Staff stated that the front gate is usually closed but because there was a visitor at the time, staff left the gate open and R1 went out without staff noticing. Once staff noticed R1 was gone, staff went out to look for her/him and filed a missing person report. R1 was found safe hours later by California Highway Patrol. LPA toured the facility and observed all exit doors have alarms on them. LPA also observed a sliding door alarm on R1's sliding door located in his/her room.

The following deficiencies cited on the following 809D pursuant to title 22 rules and regulations, health and safety code.

Appeal rights were printed and given to facility staff and Exit Interview was conducted.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022
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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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: 02/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2022
Section Cited

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1569.2(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirement was not as evidenced by:
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Based on record review and interview, the licensee did not ensure Resident 1's (R1) LIC602 was being followed, and that the resident was kept safe. This poses an immediate health and safety risk to residents in care.
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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: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2022
LIC809 (FAS) - (06/04)
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