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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002950
Report Date: 04/09/2026
Date Signed: 04/09/2026 10:41:50 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/12/2026 and conducted by Evaluator Cassandra Mikkelson
COMPLAINT CONTROL NUMBER: 59-AS-20260212170248
FACILITY NAME:HOLLISTER CARE HOMEFACILITY NUMBER:
345002950
ADMINISTRATOR:OKKI KIMFACILITY TYPE:
740
ADDRESS:3734 HOLLISTER AVETELEPHONE:
(916) 860-3014
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
04/09/2026
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Okki KimTIME COMPLETED:
10:55 AM
ALLEGATION(S):
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Facility staff performed g-tube feedings for resident without training or supervision from a skilled professional
Staff are not adequately trained to safely assist residents with prescribed medications
Staff conduct poses a risk to residents in care
INVESTIGATION FINDINGS:
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Licensed Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced and met with Okki Kim to deliver findings for the above complaint allegation.

During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

*** Report continued on 9099-C***
Unfounded
Estimated Days of Completion: 10
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 59-AS-20260212170248
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: HOLLISTER CARE HOME
FACILITY NUMBER: 345002950
VISIT DATE: 04/09/2026
NARRATIVE
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Facility staff performed g-tube feedings for resident without training or supervision from a skilled professional

Interviews conducted indicated that staff were properly trained on g-tube feedings both using videos and in person visual trainings. Staff were not conducting feedings by themselves, staff were only assisting resident R1 in the feedings as R1 was still able to do most of the preparation and feeding themselves. Records reviewed indicated that feedings were documented and were done appropriately based on R1’s physician orders. All training for g-tube feedings were documented. Therefore, the allegation facility staff performed g-tube feedings for resident without training or supervision from a skilled professional is unfounded.

Staff are not adequately trained to safely assist residents with prescribed medications

Interviews conducted indicated that all staff are trained on how to properly dispense medications to residents. Staff are able to have hands on training as well to help ensure ability. Facility has procedures in place for medication passes to ensure that all medications are documented and given to the correct resident at the correct time of day. Records reviewed indicated that all staff have proper initial medication training and continuing education on dispensing medications. Staff understand the importance of properly giving medication and show their knowledge in the written question sheets in their training files. Therefore, the allegation staff are not adequately trained to safely assist residents with prescribed medications is unfounded.

Staff conduct poses a risk to residents in care

Interview with Administrator and assistant Administrator indicated that there have been no altercations between staff to their knowledge. There also has not been any altercations between the residents or staff and residents. Interviews with Resident R2 and Staff member S1 indicated there have no altercations between staff or staff and residents. Therefore, the allegation staff conduct poses a risk to residents in care is unfounded.

Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. Copy of report was given to facility.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026
LIC9099 (FAS) - (06/04)
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