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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525001919
Report Date: 04/09/2024
Date Signed: 04/09/2024 11:44:35 AM


Document Has Been Signed on 04/09/2024 11:44 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:ALOHA HOUSEFACILITY NUMBER:
525001919
ADMINISTRATOR:TIPPETTS, BARBARAFACILITY TYPE:
740
ADDRESS:13765 LISA WAYTELEPHONE:
(530) 529-1052
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY:6CENSUS: 4DATE:
04/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Barbara Tippetts - licenseeTIME COMPLETED:
12:00 PM
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04/09/2024 9:45 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Melanie Carter, care staff and explained the purpose of the visit. Licensee/administrator Barbara Tippetts ( #6003508740 exp 04/24/2025 ) arrived shortly after LPA arrived.

LPA Knight and the licensee toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to four (4) resident 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. Facility has a hospice waiver for 3 residents. Medications were reviewed

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. Hot water measured between 105 – 120 degrees F. 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 were inspected in March 2024. Smoke detectors are all operational. There are no pools/bodies of water on the premises. Last disaster drill was conducted in November 2023, next drill is scheduled for April 14, 2024.

LPA requested the following documents that need to be updated in the facility file:
LIC308 Designation of Facility Responsibility
LIC500 Personnel Report
LIC610D Emergency Disaster Plan

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 licensee Barbara Tippetts.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
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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