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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455000695
Report Date: 10/11/2022
Date Signed: 10/11/2022 03:48:52 PM

Document Has Been Signed on 10/11/2022 03:48 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:
10/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Facility Manager Tamy DefalcoTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Jacob Williams arrived at the facility unannounced on 10/11/2022 to conduct a Required 1 Year Inspection utilizing the infection control domain. LPA met with Facility Manager Tamy Defalco and explained the purpose of the visit. Prior to beginning 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, ensured they applied hand sanitizer before entering the facility, and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA and staff toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, three (3) client rooms, two (2) client bathrooms, kitchen, and outdoor area. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA and staff completed the infection control domain together 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 left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Jacob Williams
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2022
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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