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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525920005
Report Date: 06/11/2024
Date Signed: 06/11/2024 11:49:00 AM

Document Has Been Signed on 06/11/2024 11:49 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 WILDER HOUSEFACILITY NUMBER:
525920005
ADMINISTRATOR/
DIRECTOR:
PUCKETT, CHASEFACILITY TYPE:
735
ADDRESS:12875 WILDER ROADTELEPHONE:
(530) 526-0978
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 4CENSUS: 4DATE:
06/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:03 AM
MET WITH:Chase Puckett - dministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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06/11/2023 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Chase Puckett 6060358735 exp.08/08/2025 and Dawn Jackson and explained the purpose of the visit.

LPA Knight and the administrator 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. Administrator certificate is current. Medications were reviewed. 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 inspected. Smoke detectors are all operational. No pools/bodies of water are on premises. Last disaster drill was conducted in December 2023, which was a fire drill, the facility has been conducting fire drills monthly.

A deficiency is being cited as a result of today’s inspection and is documented on the attached LIC809-D. LPA observed overgrown vegetation in back /side yard of facility. LPA observed uneven ground around area of septic tank in area next to patio.

Exit interview conducted and copy of report was provided to administrator Chase Puckett.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2024
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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Document Has Been Signed on 06/11/2024 11:49 AM - It Cannot Be Edited


Created By: Rebecca Knight On 06/11/2024 at 11:38 AM
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: PRS WILDER HOUSE

FACILITY NUMBER: 525920005

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/11/2024

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 above. LPA observed overgrown vegetation in back /side yard of facility. LPA observed uneven ground around area of septic tank in area next to patio which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/02/2024
Plan of Correction
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Licensee agrees too cut back and remove the overgrown vegetation in back /side yard of facility and even the ground around area above septic tank in the area next to patio.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024


LIC809 (FAS) - (06/04)
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