<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002690
Report Date: 10/01/2021
Date Signed: 10/08/2021 12:52:30 PM

Document Has Been Signed on 10/08/2021 12:52 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:STETSON HOME #4 INCFACILITY NUMBER:
455002690
ADMINISTRATOR:CASTILLO, VIANCAFACILITY TYPE:
735
ADDRESS:1681 STETSON WAYTELEPHONE:
(530) 262-5002
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY: 6CENSUS: 4DATE:
10/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH:Angel Doss Acting AdministratorTIME COMPLETED:
02:12 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
10/01/2021 1:00 PM Licensing Program Analyst (LPA’s) Dawn Keane and PJ Cheng arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA’s met with acting administrator (AD) Angel Doss and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA contacted AD and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95, gloves and gown.. Additionally, LPA’s Keane and Cheng were screened by AD.

LPA’s Keane, Cheng and AD toured facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, two (2) bathrooms, four (4) bedrooms kitchen, storage areas front yard and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA’s Keane, Cheng and the AD completed the infection control domain and facility was found to be in substantial compliance at this time.

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

Exit interview conducted and copy of report was emailed to AD.
SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Dawn Keane
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1