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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005465
Report Date: 01/04/2022
Date Signed: 01/04/2022 02:47:10 PM

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 HOME #2FACILITY NUMBER:
347005465
ADMINISTRATOR:RESHEMA HOLLINSWORTHFACILITY TYPE:
735
ADDRESS:6608 RODNEY COURTTELEPHONE:
(916) 383-2939
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 6DATE:
01/04/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Regional Manager Krystall Moore, LPM Stepen Richardson, Rowena Lopez (ACRC), Olivia Procida (ACRC)TIME COMPLETED:
02:45 PM
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On 1-4-2022 Licensing Program Analyst (LPA) Tirzah Hubbard conducted a office visit via Teams meeting due to COVID-19 measures. LPA met with Licensee Reshema Hollins worth, Regional Manager (RM) Krystall Moore, Licensing Program Manager (LPM) Stephen Richardson, Alta Regional Representative Rowena Lopez, and Olivia Procida.
The purpose of the office visit is to discuss COVID-19 practices and COVID-19 Vaccination procedures and technical assistance.
Krystall Moore (RM) explained COVID-19 guidelines for testing monthly with vaccinations including booster. IF a employee has a exemptions they are to test weekly.
Licensee Reshema stated,
There are a Total Staff: 6 Staff at 51st 7 staff #2 all staff are vaccinated
There are 4 staff with exemptions at 51st street care #1.
For testing I send testing links to staff and residents. I send them out for testing weekly. I do not have a tracker. None of the staff do not have the booster due to the order just going out and due by February 1, 2022. My question is, If you have an exemption for the vaccine does the exemption work for the booster as well?
RM Moore Stated," That is currently not in the regulation a this time. Staff and residents have to have the booster" My next question is when will you have the tracker done?
Licensee stated, " I can complete the tracker tomorrow 1-5-22. For Home number 1 and 2 I will conduct two rounds for testing. The first round will be Wednesday 1-5-21 and the next round will be next week. We have had an issue with purchasing rapid test for the facility. All staff are wearing the surgical N95. Exemptions letters were also sent out. Requested steps for Covid-19 guidelines: 1. Tracker sheet 2. (excel spreadsheet) Date the time of positive residents. 3. A blank Line list for response testing that has to be sent everyday until facility is clear.

LPM Richardson will send PIN21-53-ASC PIN21-34-ASC over that explains guidelines. Community resources for testing sites.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah HubbardTELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022
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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