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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455001107
Report Date: 06/22/2022
Date Signed: 06/22/2022 11:36:40 AM

Document Has Been Signed on 06/22/2022 11:36 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:MID VALLEY PROVIDERSFACILITY NUMBER:
455001107
ADMINISTRATOR:MOORE, PATRICIAFACILITY TYPE:
735
ADDRESS:5193 DEBBIE LANETELEPHONE:
(530) 605-3066
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 4CENSUS: 4DATE:
06/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Janie Williams - house managerTIME COMPLETED:
12:00 PM
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6/22/2022 11:25 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Janie Williams, house manager, LPA Knight explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask, gloves. Additionally, LPA Knight was screened by Janie Williams, house manager.

LPA Knight and Mrs. Williams toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, four (4) resident bedrooms, two (2) bathrooms, kitchen, garage, and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Knight and the house manager completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report was emailed to Janie Williams house manager.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2022
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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