<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 115000591
Report Date: 04/18/2024
Date Signed: 04/18/2024 11:49:32 AM

Document Has Been Signed on 04/18/2024 11:49 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 CENTERFACILITY NUMBER:
115000591
ADMINISTRATOR/
DIRECTOR:		COYA, MICHELLEFACILITY TYPE:
775
ADDRESS:923 E SOUTH STTELEPHONE:
(530) 244-7513
CITY:ORLANDSTATE: CAZIP CODE:
95963
CAPACITY: 50CENSUS: 20DATE:
04/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Administrator- Michelle Coya TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 04/18/2024, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Michelle Coya, and explained the purpose of the visit.

LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. LPA observed the facility to be clean, in good repair and odor-free.

Areas toured include but are not limited to: common areas, and common restrooms. LPA observed each bathroom to have the necessary paper towels, trash can with lids and 20-second hand-washing poster. In the kitchen under the sink there were chemicals stored accessible to residents. The facility has a plethora of activities and supplies for scheduled activities.

LPA observed seven (7) fire extinguishers, fire detectors, and carbon monoxide detectors.

LPA reviewed a total of seven (7) residents' files and six (6) staff files which contained all of the required documentation. The facility had a completed emergency disaster plan and monthly emergency disaster drills for the LPA to review. The facility has three first aid kits that need updating.

Several topics were discussed.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code.



An exit interview was conducted, and Plans of Corrections were reviewed and developed collaboratively. A
copy of this report, LIC 809-D, and Appeal Rights were discussed and provided.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/18/2024 11:49 AM - It Cannot Be Edited


Created By: Jaynae Boyles On 04/18/2024 at 11:07 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: NORTH VALLEY SERVICES - ADULT DAY SUPPORT CENTER
FACILITY NUMBER: 115000591

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in toxic chemicals were stored under the kitchen sink accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
1
2
3
4
Licensee will ensure that all toxic chemicals are stored inaccessible to residents. Licensee will provide a training to ensure that all staff understand the importance of storing toxic chemicals inaccessible to residents.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2