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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525000233
Report Date: 06/16/2022
Date Signed: 06/16/2022 10:59:33 AM

Document Has Been Signed on 06/16/2022 10:59 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:PRS - WALBRIDGE HOUSEFACILITY NUMBER:
525000233
ADMINISTRATOR:JACKSON, DAWNFACILITY TYPE:
735
ADDRESS:2035 WALBRIDGE STTELEPHONE:
(530) 528-2131
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 6CENSUS: 4DATE:
06/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Dawn Jackson- administratorTIME COMPLETED:
11:30 AM
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06/16/2022 9:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Dawn Jackson administrator for the facility. Prior to initiating the 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask, gloves. The purpose of this visit was to conduct a case management inspection to confirm that an excluded staff was not present at or working in the facility.

The Order To Individual of Immediate Exclusion letter was issued on Jun 2, 2022 to Staff 1 (S1). S1 was associated to the following facilities:


PRS - BAKER HOUSE
PRS - MARY LANE
PRS - SOUTHPOINTE HOUSE
PRS - SOUTHPOINTE RETREAT
PRS - WALBRIDGE HOUSE
PRS - SHERMAN HOUSE

LPA spoke to administrator and explained the "Immediate Exclusion" notice indicating that S1 cannot be allowed to work, be present and/or live in a CCL licensed facility and have contact with clients in any residential facility or child day care licensed by the California Department of Social Services. Administrator Dawn Jackson indicated they understood the notice and confirmed with HR Kelly Maxwell ithat S1 was officially terminated from employment on 5/07/2022.

Administrator agrees to submit signed letter to LPA Knight by close of business 06/16/2022 that states that S1 is no longer employed by the facility.

Exit interview completed. Copy of report was emailed to administrator Dawn Jackson.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2022
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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