455002046-9-7-2023-59-AS-SBEN-CT3R9P-20230623124951

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 455002046
Report Date: 06/23/2023
Date Signed: 09/07/2023 02:05:39 PM

Document Has Been Signed on 09/07/2023 02:05 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	PEREGRINE HOME		FACILITY NUMBER:	455002046
ADMINISTRATOR:	BRANSCOMB, KALEB		FACILITY TYPE:	735
ADDRESS:	1163 PEREGRINE WAY		TELEPHONE:	(530) 262-0967
CITY:	REDDING	STATE: CA	ZIP CODE:	96003
CAPACITY: 4		CENSUS: 4	DATE:	06/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:04 AM
MET WITH:	Kaleb Branscomb Administrator		TIME COMPLETED:	01:05 PM

NARRATIVE

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Report amended 07-28-2023.

06/23/2023 11:00 AM Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Kaleb Branscomb Administrator and explained the purpose of the visit.

LPA Benson and the administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to four (4) resident rooms, common areas, two (2) bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed. Medications were also reviewed.

Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Medication is locked in a locked closet.

Administrator certificate is current. First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. All required postings are displayed within facility.

No pools/bodies of water are on premises. No firearms are on premises. Last disaster drill was conducted and documented on 06-09-2023, the facility has been conducting drills every month.

The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted and copy of report was provided to Kaleb Branscomb Administrator.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

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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Document Has Been Signed on 09/07/2023 02:05 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/28/2023 04:29 PM

Created By: Sarah Benson On 06/23/2023 at 12:48 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PEREGRINE HOME	FACILITY NUMBER: 455002046
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, The licensee did not comply with the section cited above based on chemicals under resident sink, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2023
	Plan of Correction
1 2 3 4	Licencee secured chemicals while LPA was present. Licencee will submit staff training reguarding chemicals succured in the facality by the POC date 08-16-2023.

Type B

Section Cited

CCR

85076(d)(1)

Food Service

(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that the facality did not have a seven day supply of non-perishable food at the facility, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/23/2023
	Plan of Correction
1 2 3 4	Licencee will keep a seven day supply of food stocked at the facality at all times. Licencee agrees to submit a statement of understanding of the regulation to keep a seven day supply of food.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Lauren Crocker

LICENSING EVALUATOR NAME:

Sarah Benson

LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

LIC809 (FAS) - (06/04)

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