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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455920124
Report Date: 03/05/2024
Date Signed: 03/05/2024 11:35:16 AM

Document Has Been Signed on 03/05/2024 11:35 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:JD RESIDENTIAL-QUAIL HOLLOW VILLAFACILITY NUMBER:
455920124
ADMINISTRATOR:BATTLE, TIFFANYFACILITY TYPE:
740
ADDRESS:10587 QUAIL HOLLOW DRTELEPHONE:
(530) 209-8364
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY: 4CENSUS: 0DATE:
03/05/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jeremy Potter - licenseeTIME COMPLETED:
11:40 AM
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03/05/2024 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility to conduct a Pre-Licensing inspection. LPA met with licensee Jeremy Potter, administrator Tiffany Battle, and LVN Domenique Potter and explained the purpose of the visit.

Comp 3 was waived by licensee as they are currently licensed for five other facilities.

The fire marshal has approved the fire safety inspection request. The facility is licensed for a total capacity of 4 ambulatory and 1 non-ambulatory clients.

The inside of the facility was observed to be in good condition and repair. The facility has four (4) bedrooms, three (3) bathrooms, kitchen, dining room, living room, twwo activity areas, office, laundry closet, and patio. LPA observed a dining table with four chairs in the dining room. LPA observed couch, recliner, television and seating bench in the living room. The facility has two activity rooms, one has two easy chairs and a shelf with games and books, the second has two chairs with a small activity table and a television that will be used for karaoke.

Food storage meets Title 22 regulation requirements. Plates, utensils, pots, and pans will be moved over from the previous location. Dishwasher, stove, microwave and refrigerator were all present and working.

The facility has one fully charged fire extinguisher which was 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: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
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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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: JD RESIDENTIAL-QUAIL HOLLOW VILLA
FACILITY NUMBER: 455920124
VISIT DATE: 03/05/2024
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The bedrooms are furnished with all required furniture and lighting. Each bedroom has ample storage. The facility has a linen closet where sheets, pillowcases ,and towels will be stored. Bathrooms were observed to be in good repair.
Continued on

Medications are to be stored in a locked closet. Resident and staff files will be stored in a locked office.


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

The back yard has a nice, covered patio and lawn area. LPA observed a table and chairs for residents to use.

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

No deficiencies according to CCR Title 22, Division 6. Exit Interview and copy of report was provided to the licensee.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC809 (FAS) - (06/04)
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