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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002964
Report Date: 05/07/2024
Date Signed: 05/07/2024 12:57:02 PM

Document Has Been Signed on 05/07/2024 12:57 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:CHURN CREEK BOTTOMFACILITY NUMBER:
455002964
ADMINISTRATOR/
DIRECTOR:
NUSS, JACOBBFACILITY TYPE:
735
ADDRESS:7149 CHURN CREEK ROADTELEPHONE:
(530) 782-2572
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 4CENSUS: 0DATE:
05/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Jeff CurtisTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 05/07/2024 Licensing Program Analyst (LPA) Ivan Avila arrived at the facility unannounced to conduct a 1-year annual inspection and met with Jeff Curtis and explained the purpose of the visit. LPA Avila and Administrator toured facility together. The current census at the facility is zero (0) licensed for four (4). There are no clients living at the facility.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. The facility currently does not have food at the facility as they are waiting for clients for admission. Sharp objects are stored in a locked area. Water temperature measured at 114 degrees. Bedrooms: The LPA observed resident bedrooms furnished with at least one night stand, bed, and sufficient lighting for each resident when the facility accepts clients. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, and blankets. Bathrooms: The LPA observed the resident bathrooms to be clean, and properly supplied. Common Areas: These included but are not limited to the living area, activity area, 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 firearms or bodies of water on the premises. Medications: There are no medications in the facility as of yet.

No deficiencies cited during today's visit. Exit interview conducted and a copy of the report was provided.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2024
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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