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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525920064
Report Date: 01/10/2024
Date Signed: 01/10/2024 10:59:01 AM

Document Has Been Signed on 01/10/2024 10:59 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:MASON'S RESIDENTIAL HOMES INC #1FACILITY NUMBER:
525920064
ADMINISTRATOR:MASON, GAILFACILITY TYPE:
735
ADDRESS:1460 KIMBALL RDTELEPHONE:
(530) 527-9507
CITY:RED BLUFFSTATE: CAZIP CODE:
96080
CAPACITY: 4CENSUS: 4DATE:
01/10/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:David Mason - licenseeTIME COMPLETED:
11:15 AM
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01/10/2024 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility to conduct their scheduled pre-licensing inspection. LPA met with licensees Dave and Gail Mason and Justin Bryant care staff and explained the purpose of the visit. Licensee waived COMP III presentation as they have been operating multiple facilities for several years.

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) client bedrooms, one (1) staff room, and two (2) bathrooms. LPA observed a large dining table with 4 chairs in the dining room. LPA observed a large couch in the common area with anple room for client seating.



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

Continued on LIC809-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2024
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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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: MASON'S RESIDENTIAL HOMES INC #1
FACILITY NUMBER: 525920064
VISIT DATE: 01/10/2024
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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.

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

There is a office space where client and staff files are stored in a locked cabinet.

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: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC809 (FAS) - (06/04)
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