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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525001820
Report Date: 02/15/2024
Date Signed: 02/15/2024 11:24:25 AM

Document Has Been Signed on 02/15/2024 11:24 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PRS - MARY LANEFACILITY NUMBER:
525001820
ADMINISTRATOR:HARRONG, MENDILLAFACILITY TYPE:
735
ADDRESS:200 MARY LNTELEPHONE:
(530) 527-5362
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 6CENSUS: 4DATE:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Dawn Jackson - administratorTIME COMPLETED:
11:30 AM
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02/15/2024 10:40 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Dawn Jackson ( 6049860735 exp.09/30/2024 ) and explained the purpose of the visit. An annual inspection was also completed at the facility on 11/30/2024.

LPA Knight and the administrator toured the facility together to ensure the health and safety of clients in care. The facility was remodeled within the past year with new flooring throughout, new kitchen and bathroom counter tops, new kitchen cabinets, new appliances, new paint throughout the facility. Areas toured include but are not limited to four (4) client rooms, common areas, two (2) bathrooms, kitchen, storage areas and back yard. Staff and resident files were reviewed. All employees requiring background checks are cleared. Administrator certificate is current. Medications were reviewed.

There is a schedule of recreational activities planned for the clients. Bedding, linens, and towels for clients were observed and found to be clean and in good repair. There is an adequate supply of toiletries for the clients. Medication is locked in a cabinet.

The facility was observed to be at a comfortable temperature. Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and inspected. Smoke detectors are all operational. No pools/bodies of water are on premises. No firearms are on premises. Last disaster drill was conducted in October 2023 which was a fire drill, the facility has been conducting fire drills monthly and various disaster drills every 3 months.

In the areas toured no immediate health, safety, or personal rights violations were observed. No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report was provided to administrator Dawn Jackson.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024
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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