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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455001419
Report Date: 09/06/2023
Date Signed: 09/06/2023 11:10:11 AM

Document Has Been Signed on 09/06/2023 11:10 AM - 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: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: 40DATE:
09/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Kathaleen Waltz TIME COMPLETED:
11:30 AM
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On 09/06/2023, Licensing Program Analysts (LPAs) Ivan Avila and Jaynae Boyels, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPAs met with Licensee Kathleen Waltz and explained the purpose of the visit.

LPA Avila, LPA Boyels, and Licensee Waltz toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, garage, front yards, and common restrooms. LPA observed the facility to be clean, in good repair and each bathroom to have the paper towels, trash can with lids. Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Hot water temperature was measured within the required range. LPA observed two (2) fire extinguishers, fire detectors, and carbon monoxide detectors. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of five (5) residents' files and three (3) staff files.

Several topics were discussed.

There were no deficiencies cited at this time.

Exit interview conducted and copy of report left at the facility.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2023
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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