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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525001820
Report Date: 02/06/2023
Date Signed: 02/07/2023 01:34:46 PM

Document Has Been Signed on 02/07/2023 01:34 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,
, CA
FACILITY NAME:PRS - MARY LANEFACILITY NUMBER:
525001820
ADMINISTRATOR:SCHLOTTMAN, LAURIEFACILITY TYPE:
735
ADDRESS:200 MARY LNTELEPHONE:
(530) 527-5362
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 6CENSUS: 4DATE:
02/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Mindee Harong - AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Inspection Visit utilizing the infection control domain. LPA met with administrator and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally LPA was screened by facility staff.

LPA Wallace and administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, bathrooms, kitchen, storage areas, and office. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Wallace and the administrator completed the infection control domain and facility was found to be in substantial compliance at this time.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 112.2 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Smoke and carbon monoxide detectors are in compliance with fire safety. LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to clients. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed two (2) resident and two (2) staff files, including criminal record clearances. LPA reviewed Fingerprint clearance and associations to the facility. First aid kit was checked and is complete.

No deficiencies are being cited as a result of today's inspection.

Exit interview conducted and copy of report was provided to administrator at facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2023
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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