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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455000695
Report Date: 08/20/2021
Date Signed: 08/20/2021 12:05:03 PM

Document Has Been Signed on 08/20/2021 12:05 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:HAWKINS RESIDENTIAL FACILITY #2FACILITY NUMBER:
455000695
ADMINISTRATOR:KINGSLEY, SHERRIEFACILITY TYPE:
735
ADDRESS:1592 LACEY LANETELEPHONE:
(530) 221-5429
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY: 6CENSUS: 6DATE:
08/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Facility Manager Tamy DefalcoTIME COMPLETED:
12:30 PM
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On 8/20/2021 11:15 AM Licensing Program Analyst (LPA) Misty Valencia arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Facility Manager (FM) Tamy Defalco and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask, gloves

LPA Valencia and Facility Manager Tamy Defalco toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, three (3) resident shared bedrooms, two (2) bathrooms, kitchen, storage areas, and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Valencia and the Facility Manager Tamy Defalco completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report was emailed to Facility Manager Tamy Defalco.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Misty Valencia
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
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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