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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002267
Report Date: 07/25/2023
Date Signed: 07/25/2023 03:39:31 PM

Document Has Been Signed on 07/25/2023 03:39 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:MONIKA'S RESIDENTIAL CAREFACILITY NUMBER:
455002267
ADMINISTRATOR:NORA BENTEFACILITY TYPE:
735
ADDRESS:1391 DENTON WAYTELEPHONE:
(530) 222-2149
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 6CENSUS: 5DATE:
07/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Administrator Nora BenteTIME COMPLETED:
02:45 PM
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On 07/26/2023, Licensing Program Analysts (LPA)'s Jaynae Boyles and Kerry Hiratsuka, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA's met with Facility Administrator, Nora "Monika" Bente and explained the purpose of the visit.

LPA's Boyles, Hiratsuka and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, garage, backyard, and common restrooms. LPA's 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 and 20-second hand-washing poster. Facility has a 2-day perishable and a 7-day non-perishable amount of food. Hot water temperature was measured at 110 F. LPA's observed three (3) fire extinguishers which are in need of servicing, fire detectors, and carbon monoxide detectors. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA's reviewed a total of two (2) residents' files and two (2) staff files.

Fire extinguishers are a month out of date. Administrator stated she called in May to schedule the appointment to get them serviced and stated in the past they have also arrived unannounced. Administrator stated she is going to call them today and make an appointment. The tag shows the extinguishers are normally serviced on time. This is the reason a deficiency is not cited.

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: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2023
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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