525920005-8-1-2023-59-AS-RKNT-CUAR9N-20230801124948

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 525920005
Report Date: 08/01/2023
Date Signed: 08/01/2023 12:50:40 PM

Document Has Been Signed on 08/01/2023 12:50 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:	PRS WILDER HOUSE		FACILITY NUMBER:	525920005
ADMINISTRATOR:	PUCKETT, CHASE		FACILITY TYPE:	735
ADDRESS:	12875 WILDER ROAD		TELEPHONE:	(530) 526-0978
CITY:	RED BLUFF	STATE: CA	ZIP CODE:	96080
CAPACITY: 4		CENSUS: 0	DATE:	08/01/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Chase Puckett - administrator		TIME COMPLETED:	01:00 PM

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08/01/2023 11:30 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility to conduct their scheduled pre-licensing inspection. LPA met with administrators Chase and Tanner Puckett, and Licensee Gayle Palmer, and explained the purpose of the visit.

Administrators and licensee waived the Comp 3 presentation as they already have several licensed facilities and have seen the presentation before.

LPA toured the facility inside and out. The inside of the facility was observed to be in good condition and repair. The facility has received fire clearance for four (4) ambulatory clients. The facility has four (4) bedrooms and two (2) bathrooms which are set up with paper towels and soap for hand washing. LPA observed a dining table and 4 chairs in the dining room. LPA observed a sofa and 2 chairs in the common area.

Food storage meets Title 22 regulation requirements. Plates, utensils, pots, and pans were in place during the inspection. Dishwasher, stove, microwave, and refrigerator were all present and working.

The facility has 2 fully charged fire extinguisher which have been inspected by the fire marshal. LPA observed smoke alarms and carbon monoxide detectors fully functioning.

Bedrooms were observed to have furniture as required by Title 22 Regulations. All beds were made up with linens and bedspreads. The facility has a linen closet which contains towels and face cloths. Bathrooms were observed to be in good repair.

Continued on LIC809-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PRS WILDER HOUSE	FACILITY NUMBER: 525920005
	VISIT DATE: 08/01/2023

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Storage and lighting are adequate in the home. Medications are to be stored in a locked cabinet. Cleaning supplies and toxins are locked up in a cabinet in the hallway. Knives are locked up.. Washer and dryer observed in place and ready for use.

There is a locking cabinet where client and staff files will be stored.

The back yard has a shaded area with a table, and chairs for the clients to use.

The applicant has passed the pre-licensing portion of the application process. LPA will contact the Central Application Bureau.

Exit Interview and copy of report was provided to the licensee.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

LIC809 (FAS) - (06/04)

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