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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 297000914
Report Date: 10/03/2023
Date Signed: 10/04/2023 10:19:01 AM

Document Has Been Signed on 10/04/2023 10:19 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:HOUSTON AND NOBLES ADULT RESIDENTIAL CAREFACILITY NUMBER:
297000914
ADMINISTRATOR:MARK & BARBARA HOUSTONFACILITY TYPE:
735
ADDRESS:21706 JOHN BORN ROADTELEPHONE:
(530) 432-3399
CITY:PENN VALLEYSTATE: CAZIP CODE:
95946
CAPACITY: 6CENSUS: 6DATE:
10/03/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Mark Houston, Josh Houston, Barbara HoustonTIME COMPLETED:
04:00 PM
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On 10/3/2023 LPA Tryon attended a meeting at the home along with staff from Alta California Regional Center. The meeting was to discuss issues found by Alta at the facility, and the Facility Action Report they have put into place.
Present from Alta California RC were:
BJ Thompson
Ebony Maldonado
Samantha Morgan

Present from the facility:
Mark Houston
Josh Houston
Barbara Houston
Kyle Houston
Various issues were discussed including issues with:
P&I records
Quarterly Reports to the ACRC
The request from ACRC for weekly notes for all residents
Need for a Health Care Plan for one resident
Need for plans and tracking for Behaviors
Request for several personnel documents
Request for a new staff schedule with hours to meet the RC level requirements
Log of monthly training for ACRC
The home has made sure hygiene caddies are available for each resident
Question regarding resident camper trailer on site.
There appears to be no action necessary from CCL at this time. An annual visit using the CARE Tool will be done in the future to check on the home regarding Title 22 compliance.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2023
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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