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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
115000591
Report Date:
04/11/2024
Date Signed:
04/11/2024 09:48:58 AM
Document Has Been Signed on
04/11/2024 09:48 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
SACRAMENTO NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
NORTH VALLEY SERVICES - ADULT DAY SUPPORT CENTER
FACILITY NUMBER:
115000591
ADMINISTRATOR/
DIRECTOR:
COYA, MICHELLE
FACILITY TYPE:
775
ADDRESS:
923 E SOUTH ST
TELEPHONE:
(530) 244-7513
CITY:
ORLAND
STATE:
CA
ZIP CODE:
95963
CAPACITY:
50
CENSUS:
27
DATE:
04/11/2024
TYPE OF VISIT:
Collateral
ANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:
Administrator- Michelle Coya
TIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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LPA arrived at the facility announced to speak with residents for a complaint that is not associated with this adult day program.
No citations issued.
Exit interview conducted and a copy of this report left at the facility.
SUPERVISORS NAME
:
Lauren Crocker
LICENSING EVALUATOR NAME
:
Jaynae Boyles
LICENSING EVALUATOR SIGNATURE
:
DATE:
04/11/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/11/2024
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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