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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 115000591
Report Date: 04/25/2022
Date Signed: 04/25/2022 11:47:53 AM

Document Has Been Signed on 04/25/2022 11:47 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:NORTH VALLEY SERVICES - ADULT DAY SUPPORT CENTERFACILITY NUMBER:
115000591
ADMINISTRATOR:CARLTON, ASHLEYFACILITY TYPE:
775
ADDRESS:923 E SOUTH STTELEPHONE:
(530) 244-7513
CITY:ORLANDSTATE: CAZIP CODE:
95963
CAPACITY: 50CENSUS: 3DATE:
04/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Shawn BurlesonTIME COMPLETED:
12:00 PM
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On 04/25/2022 at approximately 11:00 AM Licensing Program Analyst (LPA) Jaclyn Avila arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with administrative assistant Shawn Burleson, 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask.

LPA Avila and Ms. Burleson toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, bathrooms, and storage rooms. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Knight and Ms. Burleson completed the infection control domain and facility was found to be in substantial compliance at this time.

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

Exit interview conducted and copy of report was given to administrative assistant Shawn Burleson.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Jaclyn Avila
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
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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