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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002332
Report Date: 05/31/2022
Date Signed: 06/13/2022 09:01:18 AM

Document Has Been Signed on 06/13/2022 09:01 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:MDH RESIDENTIALFACILITY NUMBER:
455002332
ADMINISTRATOR:HEMSTED, TAMARIEFACILITY TYPE:
735
ADDRESS:4369 BOWYER BLVDTELEPHONE:
(530) 604-3055
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 4CENSUS: 4DATE:
05/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Tamarie HemstedTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) David Loperenal arrived at the facility unannounced on 05/31/2022 at approximately 10:55 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Tamarie Hemsted (Admin) and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPA was screened by Mackenzie Hemsted (Staff).

LPA and staff toured facility together to ensure health and safety of clients in care. Areas toured include but are not limited to: common areas, three (3) of four (4) resident bedrooms, two (2) of two (2) bathrooms, kitchen, garage, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and admin completed the infection control domain and facility was found to be in substantial compliance at this time.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: David Loperena
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2022
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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