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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002803
Report Date: 03/13/2023
Date Signed: 03/14/2023 07:35:31 AM

Document Has Been Signed on 03/14/2023 07:35 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
CCLD Regional Office,
, CA
FACILITY NAME:RIDGEVIEW RESIDENTIAL CENTERFACILITY NUMBER:
455002803
ADMINISTRATOR:SMITH, JACQUELYNFACILITY TYPE:
735
ADDRESS:2096 CASCADES BLVD. SUITE BTELEPHONE:
(530) 768-1275
CITY:SHASTA LAKE CITYSTATE: CAZIP CODE:
96019
CAPACITY: 16CENSUS: 11DATE:
03/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jacquelyn Smith - AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Inspection Visit utilizing the infection control domain. LPA met administrator and explained the purpose of the visit. Prior to initiating 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; facility 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 administrator. Administrator certificate expires 7/7/2024.

LPA and administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, and common restrooms. In the areas toured no immediate health, safety, or personal rights violations were observed. There are four private bedrooms and six shared bedrooms provided clients, kitchen, five bathrooms, dining room, living room staff office, and staff bathroom. There is an outdoor activity space with shaded areas. LPA and administrator completed the full care tool and facility was found to be in substantial compliance at this time.

LPA observed hot water temperature was measured at 119.0 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire Extinguishers were inspected on 9/9/22 and in compliance. Smoke and carbon monoxide detectors are in compliance with fire safety. LPA observed centrally stored medications locked up in medication rooms. LPA reviewed four (4) resident and five (5) staff files, including criminal record clearances. LPA reviewed Fingerprint clearance and associations to the facility. First aid kit was checked and is complete.

No deficiencies cited today.
Exit interview conducted and copy of report left with Administrator
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2023
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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