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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 290308074
Report Date: 11/02/2023
Date Signed: 11/02/2023 03:40:29 PM


Document Has Been Signed on 11/02/2023 03:40 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:BANNER CRESTFACILITY NUMBER:
290308074
ADMINISTRATOR:LINHARES, JUDITH C.FACILITY TYPE:
740
ADDRESS:12382 CASCADE WAYTELEPHONE:
(530) 272-4513
CITY:NEVADA CITYSTATE: CAZIP CODE:
95959
CAPACITY:7CENSUS: 6DATE:
11/02/2023
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Carrie TrammellTIME COMPLETED:
04:00 PM
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On 11/2/2023 LPA Tryon visited the facility to conduct a required annual visit using the CARE Tool. LPA met with Carrie Trammell.

LPA toured the facility including common areas, kitchen, dining room, bedrooms, hallways, laundry room, outside areas. The facility is clean, nicely furnished. Bedrooms are appropriately and nicely furnished. Smoke detectors installed and functional. Carbon monoxide detector installed. Units are checked regularly. Fire extinguisher charged and was recently serviced. Home conducts regular drills.
Food supplies were reviewed and appear appropriate for 6 residents for 2 days perishable and 7 days non-perishable supplies. Medications are centrally stored and locked, centrally stored logs maintained. Cleaners and chemicals are secured, as well as sharp knives and other potentially hazardous items.

LPA reviewed all staff files. File include current First Aid/CPR, updated training, health reports, fingerprint clearance, etc.

LPA reviewed 3 of 6 resident files. Files include admission agreements, assessments, plans, updated physician reports/TB clearance, inventories, medication records, face sheets, etc.

LPA did not interview residents as it was late in the afternoon, residents were having their quiet time. LPA did meet and say hello to all residents, all appeared to be doing well and comfortable,

At this time, the facility appears to be in substantial compliance with the regulations.

No deficiencies were cited at this visit. Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023
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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