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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600141
Report Date: 08/02/2022
Date Signed: 08/02/2022 02:05:47 PM

Document Has Been Signed on 08/02/2022 02:05 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HOLY HILL INC./CARFAX HOMEFACILITY NUMBER:
198600141
ADMINISTRATOR:FRANCISCO, ROBERTFACILITY TYPE:
740
ADDRESS:13831 CARFAX AVETELEPHONE:
(562) 867-3279
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 6CENSUS: 1DATE:
08/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:36 PM
MET WITH:Kerry Francisco, Administrator TIME COMPLETED:
02:30 PM
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On 8/02/22 at 12:36 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with Administrator, Kerry Francisco who assisted with today’s visit.

The facility is licensed to serve 6 clients between the age of 18 and 59 years old and vendored through Harbor Regional Center. The facility is a single-story building in a residential area, with a kitchen, dining room, 2 living room, 4 bedrooms, 1 office, 2 bathrooms, backyard with shaded area and a detached garage. Fire extinguisher observed fully charged in kitchen and hallway. There are smoke detectors/ Carbon monoxide located throughout the facility, tested and operational.



LPAs discussed infection control practices with administrator, toured the facility inside and out, reviewed food supply, reviewed staff file, and reviewed resident medication.

Report continued 809c

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2022
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HOLY HILL INC./CARFAX HOME
FACILITY NUMBER: 198600141
VISIT DATE: 08/02/2022
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Bedrooms have the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. LPA toured the kitchen and observed 7 days of perishables and 2 days nonperishable. The front and backyard are well maintained. The resident bathrooms are clean, with grab bars and non-skid materials. The hot water temperature measured at 111.9- 112.8 degrees F. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. LPA observed a sufficient supply of PPE in the garage. Infection control signs were observed throughout the facility. Medications reviewed for client and appears to be given as prescribed. Facility file reviewed revealed administrator certificate # 6057959735 expire 11/17/2023. Last emergency disaster drill 7/13/22.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided to Administrator.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
LIC809 (FAS) - (06/04)
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