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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455001470
Report Date: 06/29/2021
Date Signed: 06/29/2021 03:54:30 PM

Document Has Been Signed on 06/29/2021 03:54 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:LAKE REDDING MANORFACILITY NUMBER:
455001470
ADMINISTRATOR:CAIN, MATTHEWFACILITY TYPE:
740
ADDRESS:739 DELTA STREETTELEPHONE:
(530) 241-9566
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY: 6CENSUS: 4DATE:
06/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Desiree WrightTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) K. Hiratsuka, arrived at the facility unannounced on 06/29/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Facility Representatives Desiree Wright, Madeline Collins,and Melissa Burton and explained the purpose of the visit. Prior to initiating the visit, 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 Facility Representative 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: surgical mask. Additionally, LPA was screened by Melissa Burton.

LPA and Melissa Burton toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, and common restrooms.. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and facility staff completed the infection control domain and facility was found to be in substantial compliance at this time.

A couple of topics were discussed.



No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2021
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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