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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002332
Report Date: 05/16/2023
Date Signed: 05/16/2023 02:13:51 PM

Document Has Been Signed on 05/16/2023 02:13 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:MDH RESIDENTIALFACILITY NUMBER:
455002332
ADMINISTRATOR:HEMSTED, TAMARIEFACILITY TYPE:
735
ADDRESS:4369 BOWYER BLVDTELEPHONE:
(530) 604-3055
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 4CENSUS: 4DATE:
05/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Administrator Tamarie HemstedTIME COMPLETED:
02:45 PM
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On 05/16/2023, Licensing Program Analysts (LPA) Ivan Avila, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Tamarie Hemsted and explained the purpose of the visit. LPA ensured he used hand sanitizer shortly after entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by Direct Care Staff.

LPA Avila and Tamarie Hemsted toured facility together to ensure health and safety of clients in care. Areas toured include but are not limited to: common areas, resident bedrooms, garage, backyard, and common restrooms. LPA observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary 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 and sharps to be locked. Hot water temperature was measured at 128 F. LPA observed one (1) fire extinguisher, 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) client files and one (1) staff files. LPA also reviewed one (1) client's medication and compared it to the centrally stored medication log.

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: Ivan Avila
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2023
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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