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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002950
Report Date: 11/21/2024
Date Signed: 11/21/2024 01:35:39 PM

Document Has Been Signed on 11/21/2024 01:35 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:HOLLISTER CARE HOMEFACILITY NUMBER:
345002950
ADMINISTRATOR/
DIRECTOR:		KONG, JESSICAFACILITY TYPE:
740
ADDRESS:3734 HOLLISTER AVETELEPHONE:
(916) 860-3014
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 5DATE:
11/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Jessica KongTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection utilizing the inspection care tool. LPA met with Administrator and explained the purpose of the visit.

Today's census is five (5) residents in care with three (3) residents on hospice services. Facility is licensed for six (6) non-ambulatory and hospice waiver for 6. Facility is compliance to licensure.

During today's inspection, LPA conducted an inspection of six residents rooms, two bathrooms, kitchen and the common areas. LPA observed outside to be free of obstructions. Based on the areas toured, LPA observed no health, safety and personal rights violation. LPA observed facility to have sharps, toxins and medications to be locked and inaccessible to other residents in care.

LPA observed license and Administrator Certificate to be posted in a conspicuous space. LPA observed Administrator Certificate #7027603740 to be active with expiration date of 2/28/2026.

File review was conducted for five residents and five personnel records. LPA observed initial training completed. LPA observed documentation of annual training to be pending. LPA was informed partial training has not been inputted on file for S1 and S2.

Care tool completed and facility was found to be in compliance.

Exit interview conducted. Signature on this form acknowledges receipt of report.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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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