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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 185001662
Report Date: 07/23/2024
Date Signed: 07/23/2024 11:25:17 AM

Document Has Been Signed on 07/23/2024 11:25 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 SERVICESFACILITY NUMBER:
185001662
ADMINISTRATOR/
DIRECTOR:		HOUGH, TONYAFACILITY TYPE:
775
ADDRESS:1550 MAIN STTELEPHONE:
(530) 257-3217
CITY:SUSANVILLESTATE: CAZIP CODE:
96130
CAPACITY: 30CENSUS: 8DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Program Manager, Tonya HoughTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On July 23, 2024 at approximately 9:45 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at North Valley Services Day Program for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Program Manager, Tonya Hough and was granted access into the facility.

LPA and the Program Manager toured the Day Program. LPA observed the Day Program to be clean, safe and sanitary with all exits free from obstruction. LPA observed an activity room, two art supply rooms, a separate room where they keep the clients backpacks, chemical supply room that is locked and inaccessible to clients in care, movie room, a kitchen, two isolation rooms, another activity room and a garage where recyclable cans are kept and disposed of. Shaded Outdoor activity space was observed by the tree. Fire Extinguishers was last inspected on December 2023. All smoke detectors and carbon monoxide detectors were tested and found to be operational at the time of the inspection. Hot water temperature measured at 113 degrees in 3 of 3 clients bathrooms. Hot water temperature is within acceptable range of 105-120 degrees. Food is not served at the Day Program. Clients bring their own lunches. Client records and personnel records are kept inside the Program Managers office. Facility does not store any medications at the facility nor do they dispense medications, toxins are kept locked and inaccessible to clients in care. Facility has a first aid kit which was inspected and found to be appropriate during the inspection. There is an outdoor space for activities with a shaded area. During the Required 1 year inspection, LPA reviewed the Infection Control Plan and found that document to be appropriate. LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms of COVID-19 + or any infectious diseases in the facility. Emergency Disaster Plan was reviewed and found to be appropriate during the review.

LPA reviewed the 3 of 3 staff files and found that the facility staff do not have all their hours of training. (Report continued on LIC 809C)
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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
FACILITY NUMBER: 185001662
VISIT DATE: 07/23/2024
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LPA educated the Program Manager regarding the importance of training staff per Title 22 regulation (See LIC 9102's-Technical Violations). 7 of 7 client files were reviewed and found to be appropriate during the inspection. First aid certificates were reviewed and found to be appropriate. LPA requested the following documents:

LIC 500-Personnel Report
LIC 308-Designation of Responsibility
LIC 400- Affidavit regarding Client Cash Resources
Liability insurance
Control of Property
Client Roster
Infection Control Plan
Emergency Disaster Plan

No deficiencies were cited during the Required 1 year inspection. Exit interview was conducted and a copy of this report was emailed to the Program Manager.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
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