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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
455002559
Report Date:
10/23/2023
Date Signed:
10/23/2023 01:21:22 PM
Document Has Been Signed on
10/23/2023 01:21 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:
OAK MESA HOME
FACILITY NUMBER:
455002559
ADMINISTRATOR:
BAUGHMAN, LINDSAY
FACILITY TYPE:
735
ADDRESS:
1870 OAK MESA
TELEPHONE:
(530) 215-3973
CITY:
REDDING
STATE:
CA
ZIP CODE:
96003
CAPACITY:
6
CENSUS:
4
DATE:
10/23/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
01:00 PM
MET WITH:
Jaquie Stevens Direct Support Professional
TIME COMPLETED:
01:30 PM
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LPA Sarah Benson previously completed the required annual Inspection on 9/26/2023.
During todays inspection on 1023-23 LPA Benson met with Jaqquie Stevens DSP and discussed AWOLs and medication error incident report.
SUPERVISORS NAME
:
Lauren Crocker
LICENSING EVALUATOR NAME
:
Sarah Benson
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/23/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/23/2023
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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