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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003949
Report Date: 06/01/2023
Date Signed: 06/01/2023 02:54:18 PM


Document Has Been Signed on 06/01/2023 02:54 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:
06/01/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Crisina JacksonTIME COMPLETED:
03:30 PM
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On 6/1/23 at 2:00pm Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Case Management Inspection to address the notification of change of ownership received on 5/31/23. LPA Gould met with Licensee Crisina Jackson to discuss the department's concerns regarding the notification.

LPA and Licensee discussed the requirements for a change of ownership. LPA and the Licensee agreed that the current Licensee and administrator would continue to operate the facility as required by regulations until the new application is approved by the department and the applicant obtains a license. Licensee states she understands the departments requirements and will be operating the facility until a new license is obtained for the applicant.

The licensee indicated that residents have been notified verbally. LPA informed Licensee that the department is requesting she notify all residents and/or their authorized representatives in writing on today's date 6/1/23. LPA also asked that facility review personal rights of residents in a private facility to ensure residents understand their rights as part of the change of ownership.

LPA spoke with the new applicant and confirmed that an application has yet to be submitted to the department and the new applicant is aware that the current licensee will remain as owner of this facility until a license is approved by the department.

LPA requested and the licensee agreed to provide the department a new notification letter and include the information of the new application and state in writing that the change will take place once the new application is approved by the department and will continue to operate the facility in compliance with title 22 regulation.

Per California Code of Regulations, Title 22 no deficiencies observed during todays inspection. 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: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023
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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