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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003949
Report Date: 08/15/2022
Date Signed: 08/15/2022 03:45:57 PM


Document Has Been Signed on 08/15/2022 03:45 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:
08/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Anita OrenseTIME COMPLETED:
04:00 PM
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On 8/15/22 at 3:20 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.

On 8/7/22 Resident 1 (R1) left the facility without signing out. R1 was not back by curfew time so Administrator called the police and filed a missing person report. R1 came back the next morning showing signs of paranoia and confusion. R1's physicians report does state he/she is able to leave the facility unassisted. R1 is currently in the hospital for reassessment.

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: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2022
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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