<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 085000057
Report Date: 08/14/2023
Date Signed: 08/14/2023 03:33:46 PM

Document Has Been Signed on 08/14/2023 03:33 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:KIRKPATRICK'SFACILITY NUMBER:
085000057
ADMINISTRATOR:KIRKPATRICK, PAUL & WANDAFACILITY TYPE:
735
ADDRESS:1501 HUNTER CREEK RD.TELEPHONE:
(707) 482-1650
CITY:KLAMATHSTATE: CAZIP CODE:
95548
CAPACITY: 6CENSUS: 3DATE:
08/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Wanda KirkpatrickTIME COMPLETED:
03:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At approximately 12:15PM, Licensing Program Analyst (LPA) Chris Arnhold conducted an unannounced Annual Required inspection to this facility. LPA met with Licensee Wanda Kirkpatrick and toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. The amount of fresh and non-perishable foods was within regulation. Toxins are secure and not accessible to clients. Medication is centrally stored and secure. There is a sufficient supply of hygiene products and linens on hand for client use. Mattress pads were in place or available for Client use. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to clients. Fire extinguishers inspected were charged. Smoke detectors were tested and found to be in working order. Carbon Monoxide detector was present. Disaster Drills are conducted with the last drill conducted 3/1/2023.
At approximately 1:00PM, LPA reviewed 3 Client records which were all found to be well organized, thorough and contained the required documentation. LPA reviewed staff records and found First aid and CPR certification were current. Facility does not handle P&I money. Administrator's Certificate was not current.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Wanda Kirkpatrick and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2023
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 2
Document Has Been Signed on 08/14/2023 03:33 PM - It Cannot Be Edited


Created By: Christopher Arnhold On 08/14/2023 at 03:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: KIRKPATRICK'S
FACILITY NUMBER: 085000057

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above and does not have a current Administrator Certificate. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2023
Plan of Correction
1
2
3
4
Licensee will appoint a currently certified Administrator to cover the position until they are able to recertify themselves. New Administrator will be associated and a copy of their certification will be sent to CCL by POC date of 9/13/2023.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2