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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002111
Report Date: 12/07/2022
Date Signed: 12/07/2022 11:28:50 AM

Document Has Been Signed on 12/07/2022 11:28 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
CHICO - RESIDENTIAL, 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: 5DATE:
12/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Miguel Rodriguez- Director TIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 12/07/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Director, Miguel Rodriguez, and explained the purpose of the visit. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility.

LPA toured the interior and exterior of the facility together with ED to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, five (5) resident bedrooms, two (2) bathrooms, kitchen, staff offices, laundry room and medication room. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and ED 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.



Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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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