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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455001107
Report Date: 08/25/2023
Date Signed: 05/22/2024 07:35:36 AM

Document Has Been Signed on 05/22/2024 07:35 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: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:
08/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Administrator Mike Temme TIME COMPLETED:
01:45 PM
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Licensing Program Analysts (LPAs) Jaynae Boyles and Rebecca Knight arrived at the facility unannounced on 8/25/23 to conduct a Required-1 Year Inspection.

LPAs conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are three (4) bedrooms and one (2) bathroom for resident use. LPAs observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 110 degrees F.

LPAs checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPAs observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. LPAs observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke detectors and carbon monoxide detector are operational. Fire extinguisher and first aid kit are maintained and ready for emergency use.

LPAs checked medication storage and found medication to be locked away and inaccessible to the residents. LPAs reviewed (4) resident files and also reviewed (4) staff files. Licensee will provided a copy of certificate of liability insurance to the LPA.

As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report given at the conclusion of this visit.









SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2023
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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