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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002111
Report Date: 10/17/2024
Date Signed: 10/17/2024 03:11:07 PM

Document Has Been Signed on 10/17/2024 03:11 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/
DIRECTOR:		LANE, CINDYFACILITY TYPE:
772
ADDRESS:2640 BRESLAUER WAYTELEPHONE:
(530) 229-8058
CITY:REDDINGSTATE: CAZIP CODE:
96001
CAPACITY: 15CENSUS: 6DATE:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH: Program Manager, Kristina Black and Senior Social Worker Audrey Wood-BowersTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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On 10/17/2024, Licensing Program Analyst (LPA) Sarah Benson, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Program Manager, Kristina Black and Senior Social Worker Audrey Woodward-Bowers and explained the purpose of the visit.

LPA Benson, Progam Manager and Senior Social Worker toured the facility together to ensure the health and safety of clients in care. Areas toured include but are not limited to: common areas, four (4) resident bedrooms, two (2) restrooms and outside area. 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. Hot water temperature was measured within required Title 22 regulations of 105 degrees F and 120 degrees F. Last disaster drill was conducted and documented on 10-16-24, the facility has been conducting drills every 3 months. 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 three (3) residents' files and four (4) staff files.

Topics discussed: The last centrally stored medication destruction record was recorded 2023. Staff will create an updated medication destruction record and notify LPA by 11-17-24 of completion.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report left with Director.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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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