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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002803
Report Date: 04/26/2024
Date Signed: 04/26/2024 02:46:25 PM

Document Has Been Signed on 04/26/2024 02:46 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:RIDGEVIEW RESIDENTIAL CENTERFACILITY NUMBER:
455002803
ADMINISTRATOR/
DIRECTOR:		SMITH, JACQUELYNFACILITY TYPE:
735
ADDRESS:2096 CASCADES BLVD. SUITE BTELEPHONE:
(530) 768-1275
CITY:SHASTA LAKE CITYSTATE: CAZIP CODE:
96019
CAPACITY: 16CENSUS: 11DATE:
04/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Jacquelyn Smith AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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04/26/2024 10:15 AM Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Jacquelyn Smith (cert #6040457735 exp.7-7-??) and explained the purpose of the visit. Administrator certificate is not in the active status.

LPA Benson and administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to four (6) resident rooms, common areas, three (3) bathrooms, kitchen, storage areas and back yard. Staff and resident files were reviewed. Medications were also reviewed. Medication is locked in a locked closet.



The common area was clean and in good repair. All bedrooms had required furniture and lighting. The bathrooms were clean and in good repair. The kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food.

The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. There is a schedule of activities planned for the clients.

No pools/bodies of water are on the premises. No firearms are on premises. The last disaster drill was conducted and documented on 3-19-24, the facility has been conducting fire drills every 3 months.

The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.



Exit interview conducted, a copy of the report, and appeal rights provided to administrator Jacquelyn Smith.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2024
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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Document Has Been Signed on 04/26/2024 02:46 PM - It Cannot Be Edited


Created By: Sarah Benson On 04/26/2024 at 02:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: RIDGEVIEW RESIDENTIAL CENTER
FACILITY NUMBER: 455002803

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 2 staff files had no TB or medical reports, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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Employee will get TB test completed.
Orientation check list will be updated.
Administrator will notify LPA by email when complete.
Type B
Section Cited
CCR
85068.2(b)(1)(F)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (F) The written functional capabilities assessment specified in Section 80069.2.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in one out of four client files had no written needs and services plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Will get a copy from Dr. and place in file.
Staff training for file compliance.
Administrator will contact LPA when complete.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Sarah Benson
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024


LIC809 (FAS) - (06/04)
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