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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455920169
Report Date: 11/18/2024
Date Signed: 11/18/2024 12:15:01 PM

Document Has Been Signed on 11/18/2024 12:15 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 QUAIL HOUSEFACILITY NUMBER:
455920169
ADMINISTRATOR/
DIRECTOR:		PUCKETT, SARAHFACILITY TYPE:
735
ADDRESS:3430 QUAIL LANETELEPHONE:
(530) 526-3831
CITY:COTTONWOODSTATE: CAZIP CODE:
96022
CAPACITY: 6CENSUS: 0DATE:
11/18/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Gayle Palmer LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 11/18/2024 at 11:00 AM Licensing Program Analysts (LPA’s) Sarah Benson arrived at the facility to conduct their scheduled pre-licensing inspection. LPA met with Gayle Palmer and Mike Puckett Licensee's, Sarah Puckett and Sherry Puckett Administrators and explained the purpose of the visit.

The fire marshal has approved the fire safety inspection request. The facility is licensed for (6) six ambulatory residents. This is a remodeled facility with no residents in care at the time of the pre-licensing visit.
The facility has four (4) bedrooms and two and a half (2.5) bathrooms.
The inside of the facility was observed to be free of odor, in good condition and repair. LPA observed dining area with sufficient tables and chairs for residents. LPA observed common areas clean and in good repair..
The hot water meets the requirement for licensing within a range of 105 - 120 degrees F.
Food storage metes 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.
Bedrooms were observed to have furniture as required by Title 22 Regulations. All beds were made up with linens and bedspreads. Each bedroom has ample storage. The facility has a linen closet which contains sheets, pillowcases, towels and face cloths. Bathrooms were observed to be in good repair.
The facility has a locked medication cart which is located in the locked medication room.
Storage and lighting are adequate in the facility. Cleaning supplies and toxins are locked in a hall closet. Knives are locked up in the kitchen. Washers and dryers observed in place and ready for use.
The facility has 3 FIRE EXTINGUISHERS fully charged fire extinguishers which were inspected by the fire marshal. LPA observed smoke alarms and carbon monoxide detectors fully functioning. There is a locked space where client files will be stored. The back yard has a nice, shaded structure for residents to use.

Comp 3 was presented by LPA to licensee during the visit.


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: Sarah Benson
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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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