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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525000233
Report Date: 08/16/2022
Date Signed: 08/16/2022 11:45:29 AM

Document Has Been Signed on 08/16/2022 11:45 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: DATE:
08/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Dawn Jackson -adminstratorTIME COMPLETED:
12:00 PM
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08/16/2022 11:10 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Dawn Jackson. The purpose of this visit was to conduct a case management investigation. 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.

Today's meeting concerns an investigation into an incident report that was received from the facility on 08/12/2022 regarding an incident that occurred on 08/10/2022. It was reported that on 08/10/2022 Client 1 (C1) stated that their ankle had started to bother them, stated they had fallen the week before and didn’t have much pain until 8/10/2022. Administrator made a medical appointment for C1 immediately. On 08/10/2022 C1 was seen by their physician, during the appointment x-ray’s were taken. On 8/12/2022 C1’s physician notified the administrator that C1 had a fractured ankle and a boot was placed on C1. C1 has a follow up appointment in 2 weeks for additional x-rays.

It was learned that on Friday 08/05/2022 day program notified administrator that the client fell at program. The client was wearing wedge flip flops and tripped and fell. C1 didn’t complain of plain until 08/10/2022 and the facility gave the client ibuprofen, there was no abnormal swelling or bruising observed at this time. Administrator called C1's doctor and the soonest available appointment was 8/11/2022 at 1:30 pm. At this appointment x-rays were taken, and on 8/12/2022 x-ray results became available. On 8/16/2022 The client was issued a release to return to work.

In order to prevent this from happening again the facility has purchased new tennis shoes for C1 and they are encouraging the client to wear them every day instead of the flip flops.

No deficiencies cited. Exit interview conducted and a copy of the report was emailed to administrator Dawn Jackson

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2022
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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