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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 355202720
Report Date: 08/17/2021
Date Signed: 08/17/2021 04:50:01 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:HEART OF HOLLISTER CARE HOME, LLCFACILITY NUMBER:
355202720
ADMINISTRATOR:VASQUEZ, RONALD OLIVERFACILITY TYPE:
740
ADDRESS:630 RIVERA DRTELEPHONE:
(916) 215-5920
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY:6CENSUS: 0DATE:
08/17/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:58 AM
MET WITH:TIME COMPLETED:
11:25 AM
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At 10:57AM, LPA Steve Chang arrived at facility to conduct Case Management-Other visit.
LPA rang the bell and knocked the door, but no one opened the door. LPA did not see anybody entered or exited the facility. LPA did not observe any operation at the facility.

The purpose is today's visit is for the closure of the facility. LPA cannot contact licensee at this time by phone either.

This report, the forfeiture letter will email and mail to licensee. Facility closure survey will be provided to licensee.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
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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