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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201184
Report Date: 05/10/2024
Date Signed: 05/10/2024 01:07:18 PM

Document Has Been Signed on 05/10/2024 01:07 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/
DIRECTOR:		CALDERON CRUZ, MARIVICFACILITY TYPE:
740
ADDRESS:2495 VALLECITO WAYTELEPHONE:
(408) 594-9777
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 2DATE:
05/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Marivic Calderon Cruz, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 01/06/23 at 10AM, Licensing Program Analyst (LPA) D Panlilio conducted an infection control annual inspection and explained the purpose of the visit with administrator (ADM) who has a current administrator certificate # 6017195740 which expires on 07/02/24.

At 12:15PM, LPA inspected the facility inside and outside. One central entry point has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe. COVID-19 signs are posted throughout the facility to promote hand-washing, cough/sneeze etiquette and physical distancing. Pathways were observed to be free of obstruction and fire hazards.

A written Emergency/Disaster plan was observed posted in a bulletin board next to the kitchen. Centrally stored medications were locked in kitchen cabinets. Sharp objects were locked in the kitchen drawers underneath the kitchen island. Toxic chemicals were locked underneath the sink. There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the garage. Facility room temperature was maintained at 72 degrees Fahrenheit. Hot water temperature was measured at 109 deg F.

Continued on next page, LIC 809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HOLLYWOOD RCFE LLC
FACILITY NUMBER: 079201184
VISIT DATE: 05/10/2024
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Fire extinguisher was observed fully charged and last inspected 04/18/24. Smoke and Carbon monoxide detectors were operational. Adequate supplies of PPE were also observed stored in the garage. Facility follows daily cleaning, sanitation of frequently touched common surfaces using Clorox and Lysol disinfectants. LPA reviewed 3 staff and 2 resident files during visit.

Updated copies of the following documents were obtained from administrator:
 LIC500- Personnel Report
 LIC308- Designation of Facility Responsibility
 LIC610E- Emergency/Disaster Plan/Infection Control Plans
 Evidence of Liability Insurance

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to administrator.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC809 (FAS) - (06/04)
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