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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455000113
Report Date: 10/13/2023
Date Signed: 10/13/2023 03:36:52 PM

Document Has Been Signed on 10/13/2023 03:36 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:SHEPARD COURTFACILITY NUMBER:
455000113
ADMINISTRATOR:CARLEY, LANAFACILITY TYPE:
735
ADDRESS:1000 SHEPARD COURTTELEPHONE:
(530) 222-0765
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 6CENSUS: 2DATE:
10/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Lana CarleyTIME COMPLETED:
04:00 PM
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On 10/13/2023 Licensing Program Analyst (LPA) Ivan Avila arrived at the facility unannounced for a case management visit regarding an Incident Report that was submitted to the Department and met with Lana Carley and explained the purpose of the visit.

LPA requested documents for the resident in question. Licensee stated the facility copier was not in service. The Regulation below gives the LPA the authority to remove and copy the documents from the facility.

Per Title 22, California Code of Regulations: 80070(d)(3) Client Records. All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: Licensing representatives shall return the records undamaged and in good order within three business days following the date the records were removed.

LPA informed Licensee the documents will be returned in three business days. Licensee informed LPA that the Department can keep the records for 6 months.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2023
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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