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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002162
Report Date: 04/18/2024
Date Signed: 04/18/2024 12:18:35 PM

Document Has Been Signed on 04/18/2024 12:18 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:HOLLIDAY HOMES LARKSPURFACILITY NUMBER:
525002162
ADMINISTRATOR/
DIRECTOR:		HOLLIDAY, KATHERINEFACILITY TYPE:
735
ADDRESS:1215 LARKSPURTELEPHONE:
(530) 527-1883
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 4CENSUS: DATE:
04/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Kathy Holliday - licensee/administratorTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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04/18/2024 10::00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with care staff Cyrus Yuen and explained the purpose of the visit. Licensee Kathy Holliday arrived shortly after.

LPA Knight and staff toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to four (4) resident rooms, common areas, two (2) bathrooms, kitchen, storage areas and back yard. Staff and resident files were reviewed.

Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Medication is locked in a cabinet.

Fire extinguishers fully charged and were inspected in March 2024. Smoke detectors are all operational. All employees requiring background checks are cleared. All required postings are displayed within facility.

No pools/bodies of water are on premises. Last disaster drill was conducted in April 2024, the facility has been conducting fire drills monthly.

Continued on LIC809-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: HOLLIDAY HOMES LARKSPUR
FACILITY NUMBER: 525002162
VISIT DATE: 04/18/2024
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LPA observed items in back yard that need to be disposed of including broken desk drawer, dilapidated wooden table, broken desk chair.

There is no shaded structure or trees to provide shade to clients in the back yard. Licensee shall purchase and install appropriate shaded structure and seating ample for all clients to use.

LPA requested the following documents to update facility file:

Copy of administrator certificate, LIC308 Designation of responsibility, LIC500 Personnel Report.

Deficiencies are being cited under Title 22 as a result of today’s inspection and are documented on the attached LIC9099-D.



Exit interview conducted and copy of report was provided to licensee Kathy Holliday.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/18/2024 12:18 PM - It Cannot Be Edited


Created By: Rebecca Knight On 04/18/2024 at 11:46 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HOLLIDAY HOMES LARKSPUR
FACILITY NUMBER: 525002162

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPA observed items in back yard that need to be disposed of including broken desk drawer, dilapidated wooden table, broken desk chair.
POC Due Date: 05/02/2024
Plan of Correction
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License will dispose of all listed items. Licensee will submit photograph oas proof of correction.
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. There is no shaded structure or trees to provide shade to clients in the back yard which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2024
Plan of Correction
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Licensee has purchased and will install a large umbrella and seating ample for all clients to use. Licensee will submit photograph oas proof of correction.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Rebecca Knight
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
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