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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002803
Report Date: 09/15/2021
Date Signed: 09/15/2021 01:49:16 PM

Document Has Been Signed on 09/15/2021 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:RIDGEVIEW RESIDENTIAL CENTERFACILITY NUMBER:
455002803
ADMINISTRATOR:MONTGOMERY, KRISTAFACILITY TYPE:
735
ADDRESS:2096 CASCADES BLVD. SUITE BTELEPHONE:
(530) 681-5893
CITY:SHASTA LAKE CITYSTATE: CAZIP CODE:
96019
CAPACITY: 16CENSUS: DATE:
09/15/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jacquelyn Smith, AdministratorTIME COMPLETED:
02:30 PM
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on 09/15/2021 Licensing Program Analyst (LPA) Misty Valencia conducted an announced pre licensing visit and met with Jacquelyn Smith, Administrator. Prior to initiating the complaint 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; contacted Administrator 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: Surgical Mask. Additionally, LPA was screened by Jacquelyn Smith, Administrator.

The facility was toured inside and outside. There are four private bedrooms and six shared bedrooms provided clients, kitchen, five bathrooms, dining room, living room staff office, and staff bathroom.

The facility has a locked area for medications and a locked area for cleaning supplies. There is adequate space in bedrooms, to include bed, bedding, dresser and night stand. All fire extinguishers were inspected August 21, 2021, first aid supplies and food storage areas. There is an outdoor activity space with shaded areas.

Based upon today's inspection, the Pre-licensing inspection component III of the application process has been completed and Fire Clearance was approved. Application is ready for Centralized Application Bureau to license the facility.


No deficiencies cited today, exit interview conducted and report emailed to Administrator
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Misty Valencia
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2021
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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