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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004651
Report Date: 09/24/2022
Date Signed: 09/24/2022 02:39:22 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/24/2022 02:39 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:HOLLINSWORTH CARE HOMEFACILITY NUMBER:
347004651
ADMINISTRATOR:RESHEMA HOLLINSWORTHFACILITY TYPE:
735
ADDRESS:4125 51ST STREETTELEPHONE:
(916) 456-1241
CITY:SACRAMENTOSTATE: CAZIP CODE:
95820
CAPACITY: 4CENSUS: 3DATE:
09/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:06 PM
MET WITH:Serina Beasley and Nicholas BeasleyTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Serina Beasley and Nicholas Beasley to explain the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 122.5 degrees Fahrenheit in resident bathroom sink, which is not within the required range of 105 to 120 degrees.(Advisory given)

Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 3 resident and 2 staff files, including criminal record clearances. During the file review for the residents LPA observed two IPPs that were out dated (Advisory given). Fire drill was completed on 9/5/22.

Continued.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: HOLLINSWORTH CARE HOME
FACILITY NUMBER: 347004651
VISIT DATE: 09/24/2022
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All staff are Fingerprint cleared and associated to the facility. First aid kit was checked and is complete. LPA observed and obtained a copy of a current liability insurance policy and a current surety bond.

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

Exit interview conducted
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2