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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002911
Report Date: 08/02/2022
Date Signed: 08/02/2022 10:39:23 AM

Document Has Been Signed on 08/02/2022 10:39 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:JD RESIDENTIAL- EL CEDRO VILLAFACILITY NUMBER:
455002911
ADMINISTRATOR:POTTER, JEREMYFACILITY TYPE:
740
ADDRESS:775 EL CEDRO AVETELEPHONE:
(530) 223-1525
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 4CENSUS: 4DATE:
08/02/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jeremy Potter, AdministratorTIME COMPLETED:
10:45 AM
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On 08/02/2022 Licensing Program Analyst's (LPA's) Shannon Diegoruelas and Misty Valencia arrived at the facility unannounced to conduct visit regarding Pre-Licensing and Comp lll Orientation. LPA's met with Jeremy Potter, Administrator and Colleen Kubota, Current Administrator and explained the purpose of the visit. Prior to initiating the visit, LPA's 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's ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical mask. Additionally, LPA's was screened at the front door before entrance. There is currently only one entrance due to covid protocol and monitoring, all other doors are locked and used for exits only per regulations.

COMP II, has been completed by Centralized Application Bureau analyst who confirmed Applicant/Administrator’s understanding of following areas:

1. Facility operation: License type, client/resident populations, and program
2. Staff qualifications and responsibilities
3. Applicant and Administrator qualifications
4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions
5. Grievances, Complaints, Community resources
6. Physical plant, food service
7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property. Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulations.

cont on 809-C

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Shannon Diegoruelas
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: JD RESIDENTIAL- EL CEDRO VILLA
FACILITY NUMBER: 455002911
VISIT DATE: 08/02/2022
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LPA's toured the facility inside and out including but not limited to facility kitchen, dining room, living room, two (2) bathrooms, outside areas, and four (4) client bedrooms and two (2) other bedrooms.

All client rooms are fully furnished, and facility has sufficient activities available for clients. Both bathrooms are equipped with hand washing soap and air dryers. Exits and outside area are free of obstruction. There are no bodies of water present. There are no firearms being kept at the facility. Medications are stored and locked in a dinning room cabinet.

Smoke and carbon monoxide detectors were observed as operational. Fire extinguisher were observed as full. First aid kit was observed to be complete.



Facility is ready to be licensed by Centralized Application Bureau.

LPA's collected current license from licensee.

No deficiencies for today’s visit. An exit interview was conducted and a copy of this report, dated 08/02/2022, was emailed to Jeremy Potter, Administrator
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Shannon Diegoruelas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
LIC809 (FAS) - (06/04)
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