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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002162
Report Date: 12/07/2022
Date Signed: 12/07/2022 02:18:15 PM

Document Has Been Signed on 12/07/2022 02:18 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:HOLLIDAY HOMES LARKSPURFACILITY NUMBER:
525002162
ADMINISTRATOR:HOLLIDAY, KATHERINEFACILITY TYPE:
735
ADDRESS:1215 LARKSPURTELEPHONE:
(530) 527-1883
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 4CENSUS: 4DATE:
12/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:CaregiverTIME COMPLETED:
02:30 PM
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Licensing Program Analysts (LPA) Kevin Mknelly and Rebecca Knight conducted an unannounced case management visit on 12/7/2022. This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES.

LPAs completed required COVID-19 daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPAs completed a facility risk assessment upon arrival. LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. Additionally, LPA was screened by facility staff upon entering the facility.

LPAs met with Caregiver, Robin Howell and stated the purpose of visit. LPA Mknelly spoke with licensee, Kathy Holliday , by phone. Facility understands this is an Immediate Exclusion effective 11/10/2022 and S1 is excluded and cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility. S1 is reported to have moved out of the area.

In addition to the exclusion notifications, LPAs amended complaint findings issued on 7/22/21 for complaint control numbers 25-AS-20210329124631 and 25-AS-20210311144929 for allegations Staff handled resident in a rough manner and Facility staff members handled resident in a rough manner, respectively, based on new evidence,findings to be changed from Unsubstantiated to substantiated.

Exit interview conducted, a copy of this report provided on this date. A signature on these forms acknowledges receipt of these forms.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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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