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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002111
Report Date: 11/01/2023
Date Signed: 11/01/2023 02:48:22 PM

Document Has Been Signed on 11/01/2023 02:48 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:SHASTA COUNTY MENTAL HEALTHFACILITY NUMBER:
455002111
ADMINISTRATOR:LANE, CINDYFACILITY TYPE:
772
ADDRESS:2640 BRESLAUER WAYTELEPHONE:
(530) 229-8058
CITY:REDDINGSTATE: CAZIP CODE:
96001
CAPACITY: 15CENSUS: 7DATE:
11/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Program Manager- Kristina Black TIME COMPLETED:
02:55 PM
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On 11/1/2023, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Mental Health Program Manager, Kristina Black and Director of Shasta County Mental Health Miguel Rodriguez and explained the purpose of the visit.

LPA Boyles, Program Manager and Director of Shasta County Mental Health toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, backyard, and common restrooms.

LPA observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids.

Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Hot water temperature was measured at 113 F. LPA observed the Emergency Disaster Plan to be outdated, Program Manager and Director of Shasta County Mental Health agreed to updated and submit to the LPA in one week.

LPA observed medication, knives and toxins locked and inaccessible to residents.

LPA observed fire extinguishers, fire detectors, and carbon monoxide detectors.

In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of four (4) residents' files and four (4) staff files.

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.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023
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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