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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 185001662
Report Date: 08/10/2023
Date Signed: 08/10/2023 02:48:22 PM

Document Has Been Signed on 08/10/2023 02:48 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:NORTH VALLEY SERVICESFACILITY NUMBER:
185001662
ADMINISTRATOR:HOUGH, TONYAFACILITY TYPE:
775
ADDRESS:1550 MAIN STTELEPHONE:
(530) 257-3217
CITY:SUSANVILLESTATE: CAZIP CODE:
96130
CAPACITY: 30CENSUS: 11DATE:
08/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Tonya Hough Program ManagerTIME COMPLETED:
02:30 PM
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08/10/2023 12:15PM Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Tonya Hough Administrator.

LPA Benson and the administrator toured the facility together to ensure the health and safety of clients in care. Areas toured include but are not limited to common areas, two (2) bathrooms, kitchen and storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed.



Common area was clean and in good repair. Bathrooms were clean and in good repair. Kitchen was clean and in good repair.

First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All required postings are displayed within facility.

LPA reviewed three (3) client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. All employees requiring background checks are cleared.

No pools/bodies of water are on premises. No firearms are on premises. Last disaster drill was conducted and documented on 08-01-23, the facility has been conducting drills every month.

The facility is in compliance. No deficiencies are being cited as a result of today’s inspection.



Exit interview conducted and copy of report was provided to Tonya Hough Administrator.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2023
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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