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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 01:35:09 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:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:55 AM
MET WITH:Jessica KongTIME VISIT/
INSPECTION COMPLETED:
11:10 PM
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On November 21, 2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a required annual inspection. LPA met with Administrator and explained the purpose of the visit.

LPA is conducting an annual inspection today but this report is being generated to clear the Post-Licensing inspection in the system.

There are no citations issued on this report.

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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