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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002737
Report Date: 01/11/2023
Date Signed: 01/13/2023 03:20:03 PM

Document Has Been Signed on 01/13/2023 03:20 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:JD RESIDENTIAL SERVICES, INC-LUPINEFACILITY NUMBER:
455002737
ADMINISTRATOR:POTTER, JEREMYFACILITY TYPE:
735
ADDRESS:20230 LUPINE DRTELEPHONE:
(530) 605-1093
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 3CENSUS: 3DATE:
01/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Jeremy PotterTIME COMPLETED:
12:15 PM
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LPA Parks arrived on Wednesday January 11, 2023 to conduct the annual inspection. Prior to the visit, 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 ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask.

LPA and Administrator Jeremy toured the facility to ensure the health and safety of clients in care.

LPA and Administrator completed the infection control domain together and facility was found to be in substantial compliance at this time.

LPA obtained updated copies of LIC500 and LIC610.

No deficiencies are being cited as a result of todays inspection. Exit interview conducted. A copy of this report was left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2023
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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