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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 535002723
Report Date: 07/19/2023
Date Signed: 07/19/2023 02:41:06 PM

Document Has Been Signed on 07/19/2023 02:41 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:SHASCADE TRINITY SERVICESFACILITY NUMBER:
535002723
ADMINISTRATOR:MARTIN, MELISSAFACILITY TYPE:
775
ADDRESS:171 MASONIC AVETELEPHONE:
(530) 623-6881
CITY:WEAVERVILLESTATE: CAZIP CODE:
96093
CAPACITY: 30CENSUS: 12DATE:
07/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Melissa Martin AdministratorTIME COMPLETED:
02:45 PM
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07/19/2023 12:00 PM Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Administrator Melissa Martin and explained the purpose of the visit.

LPA Benson and the administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limit to common area, two (2) bathrooms, kitchen, storage areas and yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed.



Common area was clean and in good repair. Bathrooms were clean and in good repair. Kitchen was clean and in good repair.

First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. All required postings are displayed within facility.

No pools/bodies of water are on premises. No firearms are on premises. Last disaster drill was conducted and documented on 06-27-2023, the facility has been conducting drills every month.

No deficiencies are being cited as a result of today’s inspection.



Exit interview conducted and copy of report was provided to Melissa Martin Administrator.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2023
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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