455920004-7-11-2023-59-AS-RKNT-CTMQY6-20230711123436

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 455920004
Report Date: 07/11/2023
Date Signed: 07/11/2023 12:35:11 PM

Document Has Been Signed on 07/11/2023 12:35 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:	PRS NATHAN HOUSE		FACILITY NUMBER:	455920004
ADMINISTRATOR:	PALMER, GAYLE		FACILITY TYPE:	735
ADDRESS:	3424 NATHAN DRIVE		TELEPHONE:	(530) 200-0188
CITY:	ANDERSON	STATE: CA	ZIP CODE:	96007
CAPACITY: 4		CENSUS:	DATE:	07/11/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Sarah Puckett - administrator		TIME COMPLETED:	12:45 PM

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07/11/2023 11:30 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility to conduct their scheduled pre-licensing inspection. LPA met with administrators Sarah Puckett and Laurie Schlottman, and licensee Gayle Palmer and explained the purpose of the visit.

LPA toured the facility inside and out. The inside of the facility was observed to be in good condition and repair. The facility has received fire clearance for four (4) ambulatory clients. The facility has four (4) bedrooms and two (2) bathrooms which are set up with paper towels and soap for hand washing. LPA observed dining table and four chairs in the dining room. LPA observed a couch, love seat and chair in the common area.

Food storage meets Title 22 regulation requirements. Plates, utensils, pots, and pans were in place during the inspection. Dishwasher, stove, microwave and refrigerator were all present and working.

The facility has two (2) fully charged fire extinguisher which have been inspected by the fire marshal. LPA observed smoke alarms and carbon monoxide detectors fully functioning.

Continued on LIC809-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PRS NATHAN HOUSE	FACILITY NUMBER: 455920004
	VISIT DATE: 07/11/2023

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Bedrooms were observed to have furniture as required by Title 22 Regulations. All beds were made up with linens and bedspreads. The facility has a linen closet which contains towels and face cloths. Bathrooms were observed to be in good repair.

Storage and lighting are adequate in the home. Medications are to be stored in a locked cabinet. Cleaning supplies and toxins are locked up in a cabinet in the laundry room. Knives are locked up. Washer and dryer observed in place and ready for use.

Client files are locked in a locked cabinet. Staff files are secured at the corporate office and are immediately accessible upon request.

The back yard has a shaded patio with a table, and chairs for the clients to use.

The applicant has passed the pre-licensing portion of the application process. LPA will contact the Central Application Bureau.

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

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

LIC809 (FAS) - (06/04)

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