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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455001419
Report Date: 10/08/2022
Date Signed: 10/08/2022 02:00:23 PM

Document Has Been Signed on 10/08/2022 02:00 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: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: 39DATE:
10/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Kathleen Waltz; LicenseeTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 10/8/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Licensee, Kathleen Waltz, and explained the purpose of the visit. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask.

LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: 3 resident apartments, common areas, kitchen, laundry area, and office. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Licensee completed the infection control domain.

No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2022
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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