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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003949
Report Date: 06/23/2022
Date Signed: 06/23/2022 03:32:29 PM


Document Has Been Signed on 06/23/2022 03:32 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: 5DATE:
06/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Anita OrenseTIME COMPLETED:
03:40 PM
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On June 23, 2022 at 2:25 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 caregiver Anita Orense and stated the purpose of this inspection.

LPA followed up on Resident 1(R1) who Awol'd twice before. LPA was informed that R1 has since moved out of the facility. LPA toured the facility to verify. The facility is free of odor, clean, and in good repair. The facility has sufficient seven-day non-perishable and two-day perishable food supplies. LPA observed the centrally stored medications area to be locked and inaccessible to residents.

No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes.

Exit interview 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: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
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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