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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455000695
Report Date: 08/06/2024
Date Signed: 08/06/2024 09:38:21 AM

Document Has Been Signed on 08/06/2024 09:38 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:HAWKINS RESIDENTIAL FACILITY #2FACILITY NUMBER:
455000695
ADMINISTRATOR/
DIRECTOR:		KINGSLEY, SHERRIEFACILITY TYPE:
735
ADDRESS:1592 LACEY LANETELEPHONE:
(530) 221-5429
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY: 6CENSUS: 6DATE:
08/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:45 AM
MET WITH:House Manager, Tammy Defalco
Administrator, Sherrie Kingsley		TIME VISIT/
INSPECTION COMPLETED:
09:45 AM
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On August 6, 2024 at approximately 7:45 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Hawkins Residential Facility #2 for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by House Manager, Tammy Defalco and was granted access into the facility. Administrator arrived 40 minutes later.

LPA and the House Manager toured the facility. LPA observed the facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguishers were found to be last charged on October 2023 at the time of the inspection. All smoke detectors and carbon monoxide detectors were tested and operational during the inspection. Water temperature in 2 of 2 clients bathrooms measured at 108 degrees, within acceptable range of 105 to 120 degrees F. LPA observed sufficient perishable and non-perishable foods located in the kitchen and another refrigerator in the garage which was appropriately stocked. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. Medications were centrally stored and locked. Cleaning products and other toxins are located in the laundry room that was locked and inaccessible to clients in care. There was a supply of linens, cleaners, hygiene products and paper products available for clients. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms in clients rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of all clients bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. LPA reviewed 6 client files and found those to be appropriate during the review. LPA reviewed 3 staff files and found those to be appropriate during the review. Staff that provide Care and Supervision have valid First Aid/CPR. First Aid kit was inspected and found to be appropriate during the inspection. LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms of COVID-19 or other infectious diseases are present in the facility. (Report continued on LIC 809C)
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: HAWKINS RESIDENTIAL FACILITY #2
FACILITY NUMBER: 455000695
VISIT DATE: 08/06/2024
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 LPA reviewed the Emergency Disaster Plan and the Infection Control Plan and found those documents to be appropriate during the inspection. Emergency Disaster Drill was conducted in July 2024.

LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Facility Responsibility
LIC 309- Administrative Organization
LIC 400-Affidavit Regarding Client Cash Resources
Most up-to-date Liability insurance
Updated Surety Bond
Control of Property
Register of clients

No deficiencies were cited or observed during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator due to printer issues.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC809 (FAS) - (06/04)
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