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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455001096
Report Date: 11/17/2022
Date Signed: 11/17/2022 03:19:18 PM

Document Has Been Signed on 11/17/2022 03:19 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:HAWKINS RESIDENTIAL FACILITIESFACILITY NUMBER:
455001096
ADMINISTRATOR:HAWKINS, NATALIEFACILITY TYPE:
735
ADDRESS:2512 PENELOPE STREETTELEPHONE:
(530) 243-8082
CITY:REDDINGSTATE: CAZIP CODE:
96001
CAPACITY: 6CENSUS: 5DATE:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Margo RudyTIME COMPLETED:
03:30 PM
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LPA Hiratsuka, conducted this unannounced annual visit. LPA wore a surgical mask and observed staff wearing the mask.

This facility has a fire clearance for two non-ambulatory and four ambulatory residents for a total of six. The main entrance opens to the main sitting room and dining room. The kitchen to the right of the dining area. There is a hallway on the right of the main entrance that leads to three resident rooms, the laundry closest, full bathroom, and the door leading to the garage. The largest room has a full private bathroom.. There is a second hallway that is past the dining area that leads to the staff area, and two resident rooms. There is a door leading the backyard from that hallway. The backyard was inspected. There is a gate on the same side as the garage.

Several topics were discussed today.

LPA reviewed on resident file and one staff file.

The following shall be updated and submitted to Community Care Licensing Division by December 17, 2022:
-LIC 500 facility personnel or staff schedule
-LIC 308 designation of administrative responsibilities


No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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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