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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 355201492
Report Date: 05/09/2022
Date Signed: 05/09/2022 12:49:03 PM


Document Has Been Signed on 05/09/2022 12:49 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:SVS HOLLISTER ADULT DAY PROGRAMFACILITY NUMBER:
355201492
ADMINISTRATOR:KLUEH-OLBRING, PATRICIAFACILITY TYPE:
775
ADDRESS:340 SIXTH STREETTELEPHONE:
(831) 638-0103
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY:60CENSUS: 15DATE:
05/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Mayra Clemente TIME COMPLETED:
12:45 PM
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Licensing Program Analyst LPA Shawna Doucette conducted an Annual Inspection on this date. LPA was met by Program Director Mayra Clemente and discussed the purpose of the visit. Program Director and LPA began the tour at the front entrance of the facility.

Visitor log-in/temperature check, masks, and disinfection station was observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available for clients and visitors. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas. Facility is currently operating through zoom and has minimal clients at the facility.

Cleaning supplies were observed behind a locked cabinet. LPA observed the following personal protective equipment; hand sanitizer, gown, face shield, gloves, and masks. Staff records were reviewed for infection control training. LPA observed all facility staff wearing masks. Client files have updated emergency contact information.

No deficiencies were observed.

Exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022
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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