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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455001553
Report Date: 04/09/2024
Date Signed: 04/09/2024 10:52:34 AM


Document Has Been Signed on 04/09/2024 10:52 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:AN OSPREY RETREATFACILITY NUMBER:
455001553
ADMINISTRATOR:HARONG, MENDILLAFACILITY TYPE:
740
ADDRESS:2154 OSPREY LNTELEPHONE:
(530) 224-1168
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:6CENSUS: 4DATE:
04/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Administrator- Grace Puckett TIME COMPLETED:
11:00 AM
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On 04/09/2024, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Grace Puckett and explained the purpose of the visit.

LPA Boyles and Administrator 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, backyard, shed, and common restrooms. LPA observed the facility to be clean, in good repair and odor-free. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA observed each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids and 20-second hand-washing poster. LPA observed all bedrooms to have the required furnishings, lights and windows with screens. LPA observed medications, chemical toxins and knives to be locked and inaccessible to residents.

Facility has a 2-day perishable and a 7-day non-perishable amount of food. Hot water temperature was measured within range. LPA observed two (2) fire extinguishers, fire detectors, and carbon monoxide detectors. LPA observed a complete emergency disaster plan which has been practiced and documented several times within the last 12 months.

LPA reviewed a total of four (4) residents' files and four (4) staff files which contained all of the required documentation.

Several topics were discussed.

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

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

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
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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