<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201184
Report Date: 05/26/2022
Date Signed: 05/26/2022 04:55:57 PM

Document Has Been Signed on 05/26/2022 04:55 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Marivic Cruz, Applicant/AdministratorTIME COMPLETED:
05:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 05/26/22 at 4pm, while at the facility for another reason, Licensing Program Analyst (LPA) D Panlilio completed a Component III presentation with applicant/Administrator.

LPA discussed with applicant/Administrator the most common deficiencies cited at residential care facilities and provided the soon to be licensee sufficient information to be in substantial compliance with Title 22 regulations.

LPA also discussed with applicant/Administrator the COVID-19 infection control requirements as well as attending the informational calls, understanding the updated guidelines and printing the provider information notices (PINS) for residents, authorized representatives and staff to be aware of the updates as they become available.

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)
Page: 1 of 1