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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002730
Report Date: 09/24/2024
Date Signed: 09/24/2024 01:48:38 PM

Document Has Been Signed on 09/24/2024 01:48 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:
09/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Administrator, Bonnie GardnerTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On September 24, 2024 at approximately 01:00 PM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at IPS-Pickford Way for the purpose of conducting a Case Management-Incident Inspection. LPA was greeted at the door by Administrator, Bonnie Gardner, and was granted access into the facility.

During the Case Management-Incident Inspection, LPA was made aware the client is getting services from the Regional Center. LPA reviewed and made observations of the LIC 602/Physicians Report and Functional Capability Assessment. LPA was made aware that the Care Plan is currently being updated (See LIC 9102-Technical Violation). LPA educated the Administrator on the importance of ensuring that the Care Plans are updated as outlined in Title 22 Regulations.

Administrator reported that the facility is doing an incentive plan with the client. Administrator will be contacting the Regional Center to inquire about additional services for this client. In addition, the Administrator will also request that the client gets reappraised (See LIC 9102-Technical Violation). LPA educated the Administrator on the importance of ensuring that ALL clients in care are being observed for changes in Physical, Mental, Emotional and Social Functioning as outlined in Title 22 Regulation.

No deficiencies were cited during today's Case Management-Incident 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: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2024
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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