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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455001096
Report Date: 11/08/2023
Date Signed: 11/08/2023 01:35:31 PM

Document Has Been Signed on 11/08/2023 01:35 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 6DATE:
11/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Facility Manager- Margo Rudy TIME COMPLETED:
01:50 PM
NARRATIVE
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On 11/8/2023, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Manger Margo Rudy and explained the purpose of the visit.

LPA Boyles toured facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, garage, backyard, shed, and common restrooms.

LPA observed the facility to be clean and odor-free. LPA observed each bathroom to have the necessary paper towels, trash can with lids and each bedroom to have the required furniture.

Facility has a 2-day perishable and a 7-day non-perishable amount of food.

LPA observed one (1) fire extinguishers, six (6) fire detectors, and two (2) carbon monoxide detectors.

LPA reviewed a total of five (5) residents' files and two (2) staff files which have all the required documentation.

LPA observed mold in the resident bathroom and bedroom.

Several topics were discussed.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code.



An exit interview was conducted, and Plans of Corrections were reviewed and developed collaboratively. A
copy of this report, LIC 809-D, and Appeal Rights were discussed and provided.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
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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Document Has Been Signed on 11/08/2023 01:35 PM - It Cannot Be Edited


Created By: Jaynae Boyles On 11/08/2023 at 01:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HAWKINS RESIDENTIAL FACILITIES
FACILITY NUMBER: 455001096

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in one of two bathrooms had mold which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/29/2023
Plan of Correction
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The administrator will have the plumming repaired and the drywall replaced within three weeks. The Adminstrator will develop a plan to ensure that the faciltiy is free from mold.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023


LIC809 (FAS) - (06/04)
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