<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455920262
Report Date: 04/08/2025
Date Signed: 04/08/2025 03:16:14 PM

Document Has Been Signed on 04/08/2025 03:16 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:WILLOW SPRINGS ALZHEIMER'S SPECIAL CARE CENTERFACILITY NUMBER:
455920262
ADMINISTRATOR/
DIRECTOR:		CLARK, PATRICIAFACILITY TYPE:
740
ADDRESS:191 CHURN CREEK RDTELEPHONE:
(530) 242-0654
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY: 56CENSUS: 49DATE:
04/08/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Patricia Clark, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
April 8, 2025, 1:00 PM Licensing Program Analysts (LPA’s) Sarah Benson and Kayla Adkison arrived at the facility to conduct a pre-licensing inspection. LPA ‘s met with Executive Director, Patricia Clark and explained the purpose of the visit.

Key topics of the Comp III were discussed and the full presentation was waived.
The fire marshal has approved the fire safety inspection request. The facility is licensed for 56 non-ambulatory residents of which all may be bedridden. This facility has been previously licensed and is currently changing management companies. LPA confirmed there are currently 49 residents at the facility and 14 residents are receiving hospice services. Facility will request a new hospice wavier.

The facility has a memory care unit that has (30) bedrooms with (56) beds and (32) bathrooms.
The inside of the facility was observed to be in good condition and repair. LPA’s observed dining area with sufficient tables and chairs for residents. LPA ‘s observed common areas are clean and in good reapir.
The hot water meets the requirement for licensing within a range of 105 - 120 degrees F.

Food storage meets Title 22 regulation requirements. Plates, utensils, pots, and pans were in place during the inspection.
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. 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 janitorial rooms.
NAME OF LICENSING PROGRAM MANAGER: Lauren Crocker
NAME OF LICENSING PROGRAM ANALYST: Kayla Adkison
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 3
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: WILLOW SPRINGS ALZHEIMER'S SPECIAL CARE CENTER
FACILITY NUMBER: 455920262
VISIT DATE: 04/08/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Knives are locked up in the kitchen. Laundry room was observed to be locked and washer and dryers were ready for use. Facility observed to have (7) fire extinguishers which were inspected by the fire marshal. Exit doors were observed to have alarms.

Resident/Staff files observed to contain required paperwork.

The back yard was observed to be free of obstructions and well kept.

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 Executive Director.
NAME OF LICENSING PROGRAM MANAGER: Lauren Crocker
NAME OF LICENSING PROGRAM ANALYST: Kayla Adkison
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3