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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455001567
Report Date: 09/20/2021
Date Signed: 09/20/2021 11:10:18 AM

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:A BRAND NEW DAYFACILITY NUMBER:
455001567
ADMINISTRATOR:TAYLOR, VERNAFACILITY TYPE:
740
ADDRESS:779 KERRY-JEN COURTTELEPHONE:
(530) 223-1538
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY:26CENSUS: 24DATE:
09/20/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:SYED MAJID, ADMINISTRATORTIME COMPLETED:
11:20 AM
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Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to conduct a case management visit regarding an incident. Met with Syed Majid, Administrator.

LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA Gurriere was screened by administrator/staff person upon entering the facility.

On 08/13/21 it was reported that a resident was in the bedroom and was found face down on the floor in a pool of blood. Emergency Services (911) was contacted and the resident was taken to the hospital. The resident suffered serious injuries to include broken eye sockets, fractured cheek bones, a broken nose and brain bleeding. The resident is doing well, is in good spirits and was resting during the visit. The resident is currently healed from her injuries. In an effort to avoid falls in the future, the facility staff have placed an alarm system in the resident's room. No other falls for this resident has been reported.

An exit interview was conducted, and a copy of the report was given to the administrator. No deficiencies cited.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
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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