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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525002212
Report Date: 01/14/2025
Date Signed: 01/14/2025 03:00:50 PM

Document Has Been Signed on 01/14/2025 03:00 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MASON'S RESIDENCE IIIFACILITY NUMBER:
525002212
ADMINISTRATOR/
DIRECTOR:		MASON, ERICFACILITY TYPE:
735
ADDRESS:60 SHERMAN DRIVETELEPHONE:
(530) 527-3122
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 5CENSUS: 3DATE:
01/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Pamela Dennis - care staffTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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01/14/2025 01:30 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with staff Pamela Dennis and explained the purpose of the visit. Licensee Elizabeth Mason was unavailable for the inspection.

LPA Knight and staff toured the facility together to ensure the health and safety of clients in care. 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.

Activities are planned at the client's request and clients are taken out in the community by staff. Clients plan activities according to their own desires and abilities, the clients are very independent. 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, kitchen, bathrooms, and storage areas were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. 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. Facility has been conducting fire drills monthly.

Deficiencies are cited from California Code of regulations, Title 22 and citations are listed on the attached LIC809D. LPA observed discarded televisions and other items in the back yard. LPA observed a cabinet in front one of the exits to the back yard which is blocking the exit.

Exit interview conducted and a copy of the report was provided to licensee.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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 2
Document Has Been Signed on 01/14/2025 03:00 PM - It Cannot Be Edited


Created By: Rebecca Knight On 01/14/2025 at 02:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MASON'S RESIDENCE III
FACILITY NUMBER: 525002212

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited abov which poses a potential health, safety or personal rights risk to persons in care. LPA observed discarded televisions and other items in the back yard.
POC Due Date: 02/11/2025
Plan of Correction
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Licensee agress to remove discarded items from the facility grunds. Licensee shall submit a photograph to LPA as proof of correction.
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed a cabinet in front one of the exits to the back yard which is blocking the exit.
POC Due Date: 02/11/2025
Plan of Correction
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Licensee agrees to move cabinet that is blocking one of the exits to the back yard.Licensee shall submit a photograph to LPA as proof of correction.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Rebecca Knight
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
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