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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002911
Report Date: 08/29/2023
Date Signed: 08/29/2023 11:35:07 AM


Document Has Been Signed on 08/29/2023 11:35 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:JD RESIDENTIAL- EL CEDRO VILLAFACILITY NUMBER:
455002911
ADMINISTRATOR:BATTLE, TIFFANYFACILITY TYPE:
740
ADDRESS:775 EL CEDRO AVETELEPHONE:
(530) 209-8364
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY:4CENSUS: 4DATE:
08/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Tiffany BattleTIME COMPLETED:
11:50 AM
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On 08/29/20230 Licensing Program Analyst (LPA) Ivan Avila arrived at the facility unannounced to conduct a 1-year annual inspection and met with Tiffany Battle and Jeremy Potter and explained the purpose of the visit. LPA Avila and Administrators toured the facility.
Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. The LPA observed a sufficient supply of perishable and non-perishable food at the facility; Sharp objects are stored in locked cabinet. Hot water temperature measured at 106 degrees. Bedrooms: The LPA observed resident bedrooms furnished with at least one night stand, bed, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, and blankets. Bathrooms: The LPA observed the resident’s bathroom to be clean, and properly supplied. Residents have sufficient supplies for personal hygiene. Common Areas: These included the living, and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water or fire arms on the premises. Record Review: A review of facility files was initiated. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill. The LPA obtained Resident Roster, Staff Roster, and facility Sketch. The LPA reviewed four (4) staff, and four (4)resident files. All documents reviewed appeared complete and current. Medications: During the facility visit a medications review was initiated. Medications are centrally stored and locked in a cabinet inaccessible to residents in care; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. Exit interview conducted and copy of the report and provided to Tiffany Battle and Jeremy Potter.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 895-5033
LICENSING EVALUATOR NAME: Ivan AvilaTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023
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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