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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455001470
Report Date: 08/28/2024
Date Signed: 11/18/2024 03:37:08 PM

Document Has Been Signed on 11/18/2024 03:37 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:LAKE REDDING MANORFACILITY NUMBER:
455001470
ADMINISTRATOR/
DIRECTOR:		CAIN, MATTHEWFACILITY TYPE:
740
ADDRESS:739 DELTA STREETTELEPHONE:
(530) 241-9566
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY: 6CENSUS: 6DATE:
08/28/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:House Manager, Tiffany Odom
Administrator, Betty Cain		TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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"AMENDED" This is an amended version of the original report created on August 28, 2024 as it relates to issuing a LIC-9102 Technical Violation for a citation that was appealed (Original LIC-809 D- Citation dated for August 28, 2024 was appealed and reduced down to a LIC 9102-Technical Violation) SEE BELOW FOR LIC 9102-TECHNICAL VIOLATION.

On August 28, 2024 at approximately 1:15 PM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Lake Redding Manor for the purpose of conducting a Case Management-Deficiencies inspection. LPA was greeted at the door by House Manager, Tiffany Odom, and was granted access into the facility. Administrator arrived 10 minutes later.

On August 8, 2024, the facility reported to Community Care Licensing that there was a medication error. Administrator disclosed that there was a Medication Error as it relates to a staff member giving the wrong medication cup to a resident. Poison Control and the Primary Care Physician were notified. Staff Member that gave the wrong cup of medication to the resident was advised by the Administrator to conduct additional training (See 9102-Technical Violation). LPA reviewed the LIC 602/Physicians Report and learned that the resident can manage medications but with supervision. LPA educated the Administrator on the importance of ensuring that all residents are given the correct medication.

No deficiencies were cited. Exit interview was conducted and a copy of this report was signed and given to the Administrator.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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 11/18/2024 03:37 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/18/2024 11:33 AM


Created By: Farhaan Sarangi On 08/28/2024 at 01:33 PM
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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LAKE REDDING MANOR
FACILITY NUMBER: 455001470

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
08/28/2024
Section Cited
CCR
87465(b)

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-CITATION APPEALED AND REDUCED DOWN TO AN LIC 9102-TECHNICAL VIOLATION-SEE AMENDED CASE MANAGEMENT DEFICIENCIES INSPECTION DATED FOR AUGUST 28, 2024-
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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:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024


LIC809 (FAS) - (06/04)
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