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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201184
Report Date: 05/26/2022
Date Signed: 05/26/2022 04:51:18 PM

Document Has Been Signed on 05/26/2022 04:51 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HOLLYWOOD RCFE LLCFACILITY NUMBER:
079201184
ADMINISTRATOR:CALDERON CRUZ, MARIVICFACILITY TYPE:
740
ADDRESS:2495 VALLECITO WAYTELEPHONE:
(408) 594-9777
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 0DATE:
05/26/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Marivic Cruz, Applicant/AdministratorTIME COMPLETED:
04:45 PM
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On 05/26/22 at 3:30pm, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct a Change of Location Pre-licensing Required inspection. LPA met with Applicant/Administrator and explained the purpose of the visit. The facility currently has no residents living at the facility. LPA observed COVID signages posted in the front entrance, common areas and bathrooms.

LPA toured facility including but not limited to 4 bedrooms, 2 bathrooms, kitchen, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture (night stand, chair, closet, beds dresser). Bathrooms were equipped with grab bars and shower mats. Linens and hygiene supplies were observed inside hallway cabinets. There is sufficient lighting throughout facility. Room temperature was maintained at 74 degrees F and hot water temperature was maintained at 108.5 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 04/26/22. Pathways inside and outside were free of fire hazards and obstruction. LPA observed facility has completed COVID-19 mitigation plan dated 05/01/22 and Emergency/Disaster plan dated 04/14/22 posted in bulletin boards located near the main entrance. LPA discussed the COVID mitigation plan with ADM who stated she will incorporate the COVID infection control plan in the facility's plan of operation and submit a copy to CCLD before 06/30/2022.

No deficiencies were observed during visit. Facility is ready to be licensed.This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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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