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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002730
Report Date: 07/22/2024
Date Signed: 07/22/2024 01:49:40 PM

Document Has Been Signed on 07/22/2024 01:49 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:IPS- PICKFORD WAYFACILITY NUMBER:
455002730
ADMINISTRATOR/
DIRECTOR:		GARDNER, BONNIEFACILITY TYPE:
735
ADDRESS:20374 PICKFORD WAYTELEPHONE:
(530) 605-3605
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY: 4CENSUS: 3DATE:
07/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Administrator, Bonnie GardnerTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On July 22, 2024 at approximately 12:30 PM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at IPS-Pickford Way for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Administrator, Bonnie Gardner and was granted access into the facility. Clients were at their respective Day Programs and could not be interviewed.

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 September 2023. 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 2 of 2 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. Infection Control Plan was currently being updated and will be sent to CCL (See LIC 9102-Technical Violation). Administrator advised that the Emergency Disaster Plan is currently being updated and will be sent to CCL upon completion. LPA observed the document to be completed in its entirety and reviewed it. However, Administrator disclosed that it needs to be updated. Emergency Disaster Drills are conducted monthly with the last one occurring in July 2024.

During the Required 1 year inspection, LPAs reviewed 3 of 3 staff files and found those files to be appropriate during the inspection. LPA reviewed 3 of 3 client files and found those to be appropriate during the inspection. (Report continued on LIC 809C)
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2024
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: IPS- PICKFORD WAY
FACILITY NUMBER: 455002730
VISIT DATE: 07/22/2024
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LPA reviewed the Medication Orders and found those to be appropriate during the inspection. First aid certificates were reviewed and found to be appropriate. LPA requested the following documents:

LIC 500-Personnel Report
LIC 308-Designation of Responsibility
LIC 400- Affidavit regarding Client Cash Resources
Liability insurance
Control of Property
Client Roster
Infection Control Plan
Emergency Disaster Plan

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

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC809 (FAS) - (06/04)
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