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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455001248
Report Date: 05/19/2023
Date Signed: 05/19/2023 12:24:48 PM


Document Has Been Signed on 05/19/2023 12:24 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:WILLOW SPRINGS ALZHEIMER'S SPECIAL CARE CTR.FACILITY NUMBER:
455001248
ADMINISTRATOR:GOSTAS, DARIENFACILITY TYPE:
740
ADDRESS:191 CHURN CREEK ROADTELEPHONE:
(530) 242-0654
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:56CENSUS: 46DATE:
05/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH:Patricia ClarkTIME COMPLETED:
12:45 PM
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05/19/2023 10:00 AM Licensing Program Analyst (LPA) Sarah Benson and Ivan Avila arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA’s met with Patricia K. Clark administrator (cert #135835942 exp.03-02-24) and explained the purpose of the visit. Administrator certification is current.

LPA’s and the administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to four (4) resident rooms, common areas, (4) bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed. Medications were also reviewed.



Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Medication is locked in a locked closet.

The First aid kit is fully stocked and ready for emergency use. Fire extinguisher fully charged expiration date 07-2023. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. All required postings are displayed within facility.

No pools/bodies of water are on premises. No firearms are on premises. Last disaster drill was conducted and documented on 04-22-2023, the facility has been conducting drills every month.

No deficiencies are being cited as a result of today’s inspection.



Exit interview conducted and copy of report was provided to Administrator Patricia K Clark.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah BensonTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023
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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