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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003949
Report Date: 04/05/2023
Date Signed: 04/05/2023 12:35:14 PM


Document Has Been Signed on 04/05/2023 12:35 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
SACRAMENTO AC/SC, 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: DATE:
04/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rolito Intal (Designated Staff member in administrator's absence and Anita Orense (Caregiver) TIME COMPLETED:
12:45 PM
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LPAs Brandon Panariello and LPA Kevin Gould met with care staff Rolito Intal (designated Administrator) and Anita Orense (direct care staff) in order to evaluate the physical plant and to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms, resident bathrooms, common area and outdoor area. LPAs observed the facility to be free of odor, and in good repair. LPAs observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.
LPAs measured the water temperature. Temperature measured at 109.6 degrees F which meets the 105-120 degree Fahrenheit regulation. LPAs observed sufficient seven-day non-perishable and two-day perishable food supplies. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. First aid kit was checked and is complete. LPAs observed centrally stored medications, toxins, and sharps kept locked and inaccessible to clients. LPAs reviewed Fingerprint clearance and associations to the facility. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPAs observed the facility to have hand washing signs and COVID-19 informational signs posted throughout the facility. LPA's observed a camera in bedroom #2 that was installed by resident's family member. LPA's asked resident if he wants the camera in his room. At the time of inspection the resident stated that he wants the camera in the room, but LPA's will follow-up in two weeks to see if he changes his mind.

LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 610E Emergency Disaster Plan, Current Administrator Certificate and Liability Insurance.

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) -26-4723
LICENSING EVALUATOR NAME: Brandon PanarielloTELEPHONE: 323-558-2130
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023
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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