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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 471372608
Report Date: 01/17/2025
Date Signed: 01/17/2025 02:42:57 PM

Document Has Been Signed on 01/17/2025 02:42 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:BARKERS RESIDENTIAL CAREFACILITY NUMBER:
471372608
ADMINISTRATOR/
DIRECTOR:		CRANE, SANDEEFACILITY TYPE:
735
ADDRESS:200 4TH STREETTELEPHONE:
(530) 598-7125
CITY:MONTAGUESTATE: CAZIP CODE:
96064
CAPACITY: 15CENSUS: 10DATE:
01/17/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:32 PM
MET WITH:Juanita Potts Licensee and Administrator Erykah Timberlake-SmallTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 1-17-25 Licensing Program Analyst LPA Sarah Benson arrived to open a complaint and met with Juanita Potts Licensee and Administrator Erykah Timberlake-Small.

LPA Benson observed a pile in the yard with old beds, dressers and garbage. The facility had a bucket of dirty mop water and the window in the dinning area has spots of dirty dish water.

While observing the medication for the residents it was reported the residents clonazepam medication was empty. It was reported the resident went with out the morning and noon dose.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
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 2
Document Has Been Signed on 01/17/2025 02:42 PM - It Cannot Be Edited


Created By: Sarah Benson On 01/17/2025 at 01:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BARKERS RESIDENTIAL CARE
FACILITY NUMBER: 471372608

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/24/2025
Section Cited
CCR
80075(b)

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(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by.
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Administrator will have a staff medication training.
Administrator will request refills in a timley mannor, before medication runs out.
Administrator will noitify LPA when complete.
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A client was out of clonzapine and missed AM and Noon doses. Which poses an immediate health and safety risk to persons in care. Which poses an immediate health and safety risk to persons in care.


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Type B
02/17/2025
Section Cited
CCR80087(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients... This requirement is not met as evidenced by:
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Administrator will remove pile of garbage in the yard.
Administrator will remove the buck of dirty water in dinning area.
Administrator will clean the windows.
Administrator will notify LPA when complete.
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LPA Benson observed a pile in the yard with old beds, dressers and garbage. There was a bucket of old diry mop water in the dinning area. The window in the dinning area has diry water spashes. Which poses an immediate health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Sarah Benson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2025


LIC809 (FAS) - (06/04)
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