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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 115000591
Report Date: 05/10/2023
Date Signed: 05/10/2023 12:02:27 PM

Document Has Been Signed on 05/10/2023 12:02 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:NORTH VALLEY SERVICES - ADULT DAY SUPPORT CENTERFACILITY NUMBER:
115000591
ADMINISTRATOR:COYA, MICHELLEFACILITY TYPE:
775
ADDRESS:923 E SOUTH STTELEPHONE:
(530) 244-7513
CITY:ORLANDSTATE: CAZIP CODE:
95963
CAPACITY: 50CENSUS: 16DATE:
05/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Program Manager Michelle Coya TIME COMPLETED:
12:30 PM
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On 05/10/2023, Licensing Program Analysts (LPA) Ivan Avila, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA Avila met with Program Manager Michelle Coya and explained the purpose of the visit. LPA Avila ensured hand sanitizer was shortly used after entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA Avila and Michelle toured facility together to ensure health and safety of the clients in care. Areas toured include but are not limited to: activity areas, work shop, backyard, shed, and common restrooms. LPA observed the facility to be clean, in good repair and odor-free, and paper towels in each bathroom and 20-second hand-washing posters. LPA also observed sharps to be locked and hot water temperature was measured at 118 F. LPA observed six (6) fire extinguishers, fire detectors, and carbon monoxide detectors. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of four (4) client files and three (3) staff files.

Several topics were discussed.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report left at the facility.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2023
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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