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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600420
Report Date: 09/18/2024
Date Signed: 09/18/2024 03:17:28 PM


Document Has Been Signed on 09/18/2024 03:17 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:HOLLY PARK FAMILY HOME, INC.FACILITY NUMBER:
385600420
ADMINISTRATOR:BERRY, CONCHITA R.FACILITY TYPE:
735
ADDRESS:321 HOLLY PARK CIRCLETELEPHONE:
(415) 648-8292
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY:6CENSUS: 3DATE:
09/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Bhonnie BerryTIME COMPLETED:
03:31 PM
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On 09/18/2024, Licensing Program Analyst (LPA) Grace Donato and LPA Yi Sam Jian conducted an unannounced annual inspection. LPAs were greeted by administrator, Bhonnie Berry. LPAs explained the purpose of the visit.

The physical plant was consistent with the submitted facility sketch/floor plan. On ground level, there is living quarters for staff, washer, dryer, and two extra refrigerators.

The second floor had the living room, dining room, kitchen, bathroom, 3 bedrooms for residents, and 1 bedroom for staff. A comfortable temperature was maintained. Hot water temperature warning was posted in resident bathroom sink. Trash cans were observed to have touch free operated lids. Resident bedrooms were observed to have necessary lighting and furnishings.

Centrally stored medications are in a cabinet in the ground level inaccessible to residents. Toxins and sharps are stored appropriately and inaccessible to clients. There was sufficient supply of both perishable and nonperishable foods. Food stored in the kitchen refrigerator were properly stored. Infection control practices are reviewed: PPE supply and the environmental cleaning supply are adequate; bathrooms are equipped with soap.

All outdoor and indoor passageway were free and clear of obstruction. No accessible bodies of water or fire safety hazards observed. Fire extinguishers were adequately charged and in compliance. Carbon monoxide detector and smoke detector system inspected by licensing and met the requirements. Facility has a written emergency disaster plan. Licensee stated there are no firearms or ammunition at the facility. Licensee has at least one completed first aid kit located in the kitchen.

LPAs received copy of administrator certificate. No deficiencies were observed. An exit interview was held, and a copy of the report was provided in-person.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Yi Sam JianTELEPHONE: 916-268-3959
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024
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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