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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002559
Report Date: 11/14/2024
Date Signed: 11/14/2024 11:17:23 AM

Document Has Been Signed on 11/14/2024 11:17 AM - 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 HOMEFACILITY NUMBER:
455002559
ADMINISTRATOR/
DIRECTOR:		WILLIS, STEPHENFACILITY TYPE:
735
ADDRESS:1870 OAK MESATELEPHONE:
(530) 215-3973
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY: 6CENSUS: 5DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Administrator, Stephen WillisTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On November 14, 2024 at approximately 08:30 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Oak Mesa Home for the purpose of conducting a Required 1 year inspection. Upon arrival, LPA was greeted at the door by, Direct Care Staff, Tavarius Simmons, and was granted access into the facility. Administrator arrived 30 minutes later. Clients were at their respective Day Programs.

LPA and the Administrator toured the facility. LPA observed the facility to be clean, safe and sanitary with all exits free from obstruction. Fire Extinguishers was last inspected on July 2024. All smoke detectors and carbon monoxide detectors were tested and found to be operational at the time of the inspection. Hot water temperature measured at 106 degrees in 3 of 3 clients bathrooms. Hot water temperature is within acceptable range of 105-120 degrees. LPA observed sufficient perishable and non-perishable foods located in the fridge. Food menu was observed and found to be appropriate during the inspection. There was ample space for personal hygiene products, bedding and linens, utensils, dishes, and cook ware. Client records, personnel records, medication were locked in separate cabinets, toxins are kept locked and inaccessible to clients in care. Facility has a first aid kit which was inspected and found to be appropriate during the inspection. There is an outdoor space for activities with a shaded area. During the Required 1 year inspection, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms of COVID-19 + or any infectious diseases in the facility. Emergency Disaster Plan was reviewed during the inspection. Emergency Disaster Drill was last conducted in July 2024. Infection Control Plan was reviewed and found to be appropriate.

During the Required 1 year inspection, LPAs reviewed 5 of 5 staff files and found those files to be appropriate during the inspection. 5 of 5 Professional Crisis Management (PCM) Cards were reviewed and found to be appropriate. LPA reviewed 5 of 5 client files and found those to be appropriate during the inspection. 5 of 5 client medication orders were reviewed and found to be appropriate during the inspection. (Report continued on LIC 809C)
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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
VISIT DATE: 11/14/2024
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LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Facility Responsibility
LIC 309- Administrative Organization
Most up-to-date Liability insurance
Updated Surety Bond
Control of Property
Register of clients

No deficiencies were observed or cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was signed and given to the Administrator.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC809 (FAS) - (06/04)
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