<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003949
Report Date: 05/10/2022
Date Signed: 05/10/2022 03:08:13 PM


Document Has Been Signed on 05/10/2022 03:08 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:
05/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:29 PM
MET WITH:Crisina JacksonTIME COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 5/10/22 at 1:29 PM Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced case management inspection to follow up on an AWOL incident, which occurred on 4/28/22. LPA conducted a risk assessment call prior to entry verifying there were no active covid cases. LPA met with Administrator Crisina Jackson and stated the purpose of this inspection.

On 4/28/22 Resident 1 (R1) AWOL'd from the facility again, after previously AWOL'ing on 2/1/22. The facility put measures in place to prevent R1 from AWOL'ing. R1 AWOL'd through the front door while care staff were attending a medical emergency for a resident on hospice. There were 3 staff present at the time of this incident. After tending to the resident on hospice, caregivers made rounds checking on residents and noticed R1 was gone. After R1's previous AWOL, Administrator made sure all door alarms were working properly, which they were and has implemented more staffing. LPA observed all door alarms were working properly. R1 was given an eviction notice on 2/18/22 from Administrator due to a need of higher level of care. R1 is still residing in the facility. R1's conservator has been actively trying to find placement for R1, and the facility is constantly reminding the conservator that R1's eviction notice is overdue. While LPA was present, R1 tried to walk out the front door but staff stopped him/her and redirected R1.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.


SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
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 1