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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455001419
Report Date: 09/09/2021
Date Signed: 09/09/2021 01:09:31 PM

Document Has Been Signed on 09/09/2021 01:09 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:LE BRUN ADULT RESIDENTIAL CARE FACILITYFACILITY NUMBER:
455001419
ADMINISTRATOR:GALLOWAY, JANICEFACILITY TYPE:
735
ADDRESS:1066 LE BRUN LANETELEPHONE:
(530) 223-2872
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 49CENSUS: 33DATE:
09/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Kathleen Waltz; LicenseeTIME COMPLETED:
01:15 PM
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On 9/9/21 at 11:30 AM, Licensing Program Analyst (LPA) Cheng conducted an unannounced required 1-year annual inspection and met with Licensee Kathleen Waltz. Prior to initiating the visit, 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; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask and gloves. Additionally, LPA was screened by staff.

LPA Cheng toured the facility inside and out including but not limited to facility recreation room, facility residential units, kitchen area, outside area, office room, and medication room. All passageways are free of obstruction. All staff were observed to be wearing surgical masks. Facility entrance is equipped with proper COVID-19 signage and screening station. All smoke detectors were observed to be operational and fire extinguishers were observed as full. Facility has a mitigation plan in place should a COVID positive case occur. Facility has sufficient supply of perishable food, non-perishable food, medication, and PPE.

LPA Cheng completed infection control domain and observed no issues or concerns. LPA will e-mail additional infection control posters to add to existing ones in the facility.

Exit interview conducted and a copy of report was given.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Pheej Cheng
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2021
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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