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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525000407
Report Date: 03/30/2022
Date Signed: 03/30/2022 12:41:33 PM

Document Has Been Signed on 03/30/2022 12:41 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:PRS - BAKER HOUSEFACILITY NUMBER:
525000407
ADMINISTRATOR:GATES, MARYFACILITY TYPE:
735
ADDRESS:14062 BAKER RDTELEPHONE:
(530) 529-9339
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 6CENSUS: 4DATE:
03/30/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Dawn Jackson - administratorTIME COMPLETED:
01:00 PM
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03/30/2022 12:00 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a case management investigation. LPA met with administrator Dawn Jackson and explained the purpose of the visit. Prior to initiating the complaint investigation 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. Additionally, LPA was screened by facility staff.

The reason for the visit is an incident report that was received on 03/28/2022, concerning incidents that occurred on 03/26/2022 and 03/27/2022 in which it was reported that a client had three unwitnessed falls within a 26 hour period.

LPA reviewed the following documents: Client's Physician's Report, and IPP. Review of resident's Physicians Report revealed they are ambulatory and have no motor impairment issues. Client states they have "bad knees."

LPA toured facility and inspected the bathroom where the client states they fell. There were no obstructions or trip hazzards noted.

Administrator stated client had no prior falls. When the client moved into the facility in May 2021 the client was attending physical therapy for unknown issue until June 2021 but the order was discontinued by the client's doctor. As a result of the recent falls the client was taken to urgent care on 3/29/2022 and was prescribed ibuprofen as an anti-inflammatory and referred to physical therapy.The client starts physical therapy on 04/01/2022. The administrator is calling the client's primary care doctor every day to schedule a follow-up but has not received a return call.



No deficiencies were cited during today's visit. An exit interview was 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: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2022
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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