525000233-9-26-2023-59-AS-RKNT-CW2SFU-20230926135056

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 525000233
Report Date: 09/26/2023
Date Signed: 09/26/2023 01:51:31 PM

Document Has Been Signed on 09/26/2023 01:51 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:	PRS - WALBRIDGE HOUSE		FACILITY NUMBER:	525000233
ADMINISTRATOR:	JACKSON, DAWN		FACILITY TYPE:	735
ADDRESS:	2035 WALBRIDGE ST		TELEPHONE:	(530) 528-2131
CITY:	RED BLUFF	STATE: CA	ZIP CODE:	96080
CAPACITY: 6		CENSUS: 4	DATE:	09/26/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Dawn Jackson - administrator		TIME COMPLETED:	01:45 PM

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09/26/2023 12:45 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Administrator Dawn Jackson. Today’s visit is regarding an incident that occurred on 08/27/2023 and was reported to licensing on 08/28/2023.

It was reported that on 08/28/2023 at 7:00 am Client 1 (C1) told staff their left foot hurt. Staff had C1 sit down so they could look their foot. Staff observed C1’s foot was bruised and asked C1 what had happened. C1 stated (on 8/28/2023) when they were getting out of staff's car C1’s foot got stuck and the car started moving. C1 stated the staff didn't realize C1 wasn't all of the way out of the car and C1 fell.

During the course of the investigation, it was learned that C1 had gone to another facility that their spouse lives in. During the visit C1, their spouse and staff from that facility went to visit an acquaintance. When C1 was exiting the vehicle the staff didn’t realize it and started to move the care which caused C1 to fall and injure their foot. This staff is not employed by Puckett Residential Services. The staff and C1’s spouse helped them up and C1 stated they were fine at that time. When C1 came home they didn’t say a word and then Monday morning they complained of pain and staff took C1 to the ER where C1 was diagnosed with a sprained foot, a foot brace was placed on C1's foot. C1 followed up with their primary care physician. physical therapy was ordered and starts on 9/27/2023. C1 said their foot is feeling better. Far Northern Regional Center has been notified of the incident, C1 is their own responsible party.

The staff that was transporting C1 is not employed by Puckett Residential Services. No deficiencies were cited as a result of today’s visit.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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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