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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
525002212
Report Date:
01/26/2023
Date Signed:
01/26/2023 01:32:08 PM
Document Has Been Signed on
01/26/2023 01:32 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
CHICO - RESIDENTIAL
,
520 COHASSET RD., STE. 170
CHICO
,
CA
95926
FACILITY NAME:
MASON'S RESIDENCE III
FACILITY NUMBER:
525002212
ADMINISTRATOR:
MASON, ERIC
FACILITY TYPE:
735
ADDRESS:
60 SHERMAN DRIVE
TELEPHONE:
(530) 527-3122
CITY:
RED BLUFF
STATE:
CA
ZIP CODE:
96080
CAPACITY:
5
CENSUS:
4
DATE:
01/26/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
12:20 PM
MET WITH:
Babe Mason, Cliff Taylor and Margaret Waldron
TIME COMPLETED:
01:40 PM
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LPA Hiratsuka conducted this unannounced annual visit. LPA wore a surgical mask and observed all staff wearing masks.
LPA toured the facility with Caregiver Margaret Waldron. LPA looked into three of four resident rooms. The food supply and personal protection equipment supply was checked. One staff and one resident records were checked.
A couple of topics were discussed.
No deficiencies cited
SUPERVISORS NAME
:
Lauren Crocker
LICENSING EVALUATOR NAME
:
Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE
:
DATE:
01/26/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/26/2023
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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