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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002702
Report Date: 08/21/2023
Date Signed: 08/21/2023 11:29:33 AM

Document Has Been Signed on 08/21/2023 11:29 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:LONG DRIVE HOUSEFACILITY NUMBER:
455002702
ADMINISTRATOR:BARZIN, DARAFACILITY TYPE:
735
ADDRESS:4296 LONG DRIVE CTTELEPHONE:
(530) 221-0424
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 6CENSUS: 4DATE:
08/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Jesse FloydTIME COMPLETED:
11:45 AM
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On 08/21/2023 Licensing Program Analyst (LPA) Ivan Avila arrived at the facility unannounced to conduct a 1-year annual inspection and met with House Lead Jesse Floyd and explained the purpose of the visit.
Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. The LPA observed a sufficient supply of perishable and non-perishable food at the facility. Sharp objects are stored in locked drawer. Bedrooms: The LPA observed resident bedrooms furnished with at least one night stand, bed, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, and blankets. Bathrooms: The LPA observed the resident’s bathrooms to be clean, and properly supplied. Residents have sufficient supplies for personal hygiene. Common Areas: These included the living, and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There were no obstructions and/or tripping hazards throughout the facility. Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises or fire arms in the facility. The garage: The LPA observed the garage, where the washer and dryer are held. Cleaning supplies and disinfectants are kept in locked cabinets in the garage. Medications: During the facility visit a medications review was initiated. Medications are centrally stored and locked in a cabinet inaccessible to residents in care; medications are labeled and checked for expiration dates. No errors observed during the medication review. The LPA reviewed two (2) staff files and four (4) resident files.

Several topics were discussed. Exit interview conducted and copy of the report provided to Jesse Floyd.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2023
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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