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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002111
Report Date: 11/01/2021
Date Signed: 11/01/2021 11:10:08 AM

Document Has Been Signed on 11/01/2021 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:SHASTA COUNTY MENTAL HEALTHFACILITY NUMBER:
455002111
ADMINISTRATOR:GREENE, PAIGEFACILITY TYPE:
772
ADDRESS:2640 BRESLAUER WAYTELEPHONE:
(530) 225-5200
CITY:REDDINGSTATE: CAZIP CODE:
96001
CAPACITY: 15CENSUS: 10DATE:
11/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Phillip Crawford, AdministratorTIME COMPLETED:
11:30 AM
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On 11/01/2021, Licensing Program Analysts (LPA) Misty Valencia arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Phillip Crawford, Administrator and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask. Additional LPA was screen at the front door before entering the facility by Hadinder Paul Ahlawalia (Max).

LPA Valencia and Mr Crawford toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to common areas, eight (8) resident bedrooms, two (2) bathrooms, kitchen, storage areas, and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Valencia and Mr. Crawford completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection. Copy of the report emailed to Mr
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Misty Valencia
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2021
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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