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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455003000
Report Date: 03/06/2023
Date Signed: 03/08/2023 07:22:42 AM

Document Has Been Signed on 03/08/2023 07:22 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:JD RESIDENTIAL SERVICES INC-NEMA CRISFACILITY NUMBER:
455003000
ADMINISTRATOR:POTTER, JEREMYFACILITY TYPE:
735
ADDRESS:1078 PINELAND DRTELEPHONE:
(530) 209-8364
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 4CENSUS: 4DATE:
03/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Jeremy Potter - Licensee/AdministratorTIME COMPLETED:
08:20 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ruth Wallace conducted Case Management Visit unannounced at facility. Licensee explained facility passed pre-licensing portion of the application process. Licensee asked LPA to print copy of license for facility.


No deficiencies according to CCR Title 22, Division 6.

Exit Interview and copy of report was provided to the licensee.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2023
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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