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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002964
Report Date: 07/27/2023
Date Signed: 07/27/2023 09:41:05 AM

Document Has Been Signed on 07/27/2023 09:41 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:CHURN CREEK BOTTOMFACILITY NUMBER:
455002964
ADMINISTRATOR:CURTIS, JEFFREYFACILITY TYPE:
735
ADDRESS:7149 CHURN CREEK ROADTELEPHONE:
(530) 782-2572
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 4CENSUS: DATE:
07/27/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Jacobb NussTIME COMPLETED:
09:55 AM
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On 7/27/2023 Licensing Program Analyst (LPA) Ivan Avila arrived announced at the facility to finish a Pre-licensing inspection that was started on 6/28/2023. LPA met with Administrator, Jacobb Nuss and licensee Jeff Curtis and discussed the purpose of the visit.

During today's visit, LPA Avila and Administrator toured the interior and exterior of the facility. Areas toured included but not limited to: common areas, resident bedrooms, bathroom, kitchen, and backyard, and barn. LPA observed cleaning products and other toxins to be locked away. All flooring has been installed in all rooms. LPA observed knives and sharps found to be locked and secured in the kitchen. There are four (4) fire extinguishers that are serviced and up to date. LPA observed the facility to have the required postage on the wall. LPA and Administrator complete the pre-licensing tool together on 6/28/2023, and found the facility to be at compliance.

Component III was waived during today’s inspection as Jeff Curtis is currently Administrator certified and has existing facilities. Additionally, Administrator Jacobb Nuss will be the facility administrator.

Applicant satisfied all requirements in accordance to Title 22, California Code of Regulations on today's pre-licensing inspection.

A copy of this report was provided to the facility. Exit interview conducted.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2023
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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