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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455920035
Report Date: 11/15/2023
Date Signed: 11/15/2023 11:04:48 AM

Document Has Been Signed on 11/15/2023 11:04 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:BRECKENWOOD HOUSEFACILITY NUMBER:
455920035
ADMINISTRATOR:MILLER, EMILY JANELLEFACILITY TYPE:
735
ADDRESS:1939 BRECKENWOOD DRTELEPHONE:
(530) 604-4671
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 4CENSUS: 0DATE:
11/15/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Emily Janelle MillerTIME COMPLETED:
11:20 AM
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On 11/15/2023 Licensing Program Analyst (LPA) Ivan Avila met with the Administrator Emily Janelle Miller to conduct a Pre-licensing visit. There are currently no residents. Administrator has a current certificate #6062465735 with an expiration date of 02/28/2024.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are four (4) bedrooms and two (2) bathrooms for resident use. LPA observed facility to be properly furnished, including appropriate bedding and lighting in bedrooms. Bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 115 degrees F.

LPA checked the kitchen area for the ability to prepare and store food. LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detectors at the care home to be operational. Fire extinguisher and first aid kit are maintained and ready for emergency use.

Pre-licensing passed and the Component III was conducted. Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations. Application is pending and LPA will forward findings to the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application.

Several topics were discussed.

Exit interview conducted and a copy of this report was provided to the facility.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2023
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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