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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455000113
Report Date: 10/18/2023
Date Signed: 10/18/2023 09:53:33 AM

Document Has Been Signed on 10/18/2023 09:53 AM - 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: 1DATE:
10/18/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Lana CarleyTIME COMPLETED:
10:10 AM
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On 10/18/2023 Licensing Program Analyst (LPA) Ivan Avila arrived unannounced at the facility to conduct a case management visit. LPA met with Lana Carley and explained the purpose of the visit.

During today’s visit, LPA returned R1’s resident records obtained on 10/13/2023. LPA also collected additional documents for R1. Administrator found R1s most current file in a separate room from the original documents collected. LPA informed Administrator at this time, the current matter is being under review by the Department.

LPA Avila returned the records undamaged and in good order within the required three business days following the date the records were removed.

Exit interview conducted and a copy of the report was provided.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2023
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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