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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 471372608
Report Date: 08/03/2022
Date Signed: 08/03/2022 03:20:40 PM

Document Has Been Signed on 08/03/2022 03:20 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:BARKERS RESIDENTIAL CAREFACILITY NUMBER:
471372608
ADMINISTRATOR:DAUSEL, CYNDIFACILITY TYPE:
735
ADDRESS:200 4TH STREETTELEPHONE:
(530) 905-1409
CITY:MONTAGUESTATE: CAZIP CODE:
96064
CAPACITY: 15CENSUS: 11DATE:
08/03/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Erykah and David Smalls, AdministratorTIME COMPLETED:
03:30 PM
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On 08/03/2022 Licensing Program Analyst (LPA) Misty Valencia, arrived at the facility unannounced to conduct a facility health and safety check due to a fire in the area. LPA met with Erykah and David Smalls, Administrator and explained the purpose of the visit. Prior to initiating the annual inspection visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Facility and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by the front door.

On 07/31/2022 LPA contacted Administrator regarding fire in the community. Administrator reported that they are not currently under any kind of evacuation orders, but ready if it does become a mandatory evacuation.

On 08/03/2022 Administrators report that all eleven (11) residents are packed and ready to go if need be. The plan is to go to the community center in Weed that is about thirty (30) minutes away.


No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report will be emailed.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Misty Valencia
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2022
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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