<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525000407
Report Date: 01/31/2023
Date Signed: 01/31/2023 10:59:44 AM

Document Has Been Signed on 01/31/2023 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
CHICO - RESIDENTIAL, 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: 3DATE:
01/31/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Dawn Jackson - administratorTIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
01/31/2023 10:30 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct an unannounced case management visit. LPA met with administrator Dawn Jackson. The purpose of the visit is to confirm that an excluded individual, Staff 1 (S1), is not currently working at the facility. Prior to initiating the complaint investigation LPA completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer when entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. Additionally, LPA was screened by facility staff.

LPA met with Administrator Dawn Jackson and stated the purpose of visit. Facility confirmed the receipt of the Immediate Exclusion effective 11/10/2022 that states S1 is excluded and cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. The facility understands that S1 cannot be physically present in the facility. LPA toured the facility and confirmed the excluded individual, Staff 1, was not present.

Exit interview conducted, a copy of this report provided to the administrator.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1