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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455001614
Report Date: 05/16/2023
Date Signed: 05/16/2023 11:30:44 AM

Document Has Been Signed on 05/16/2023 11:30 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:MID VALLEY PROVIDERS #4FACILITY NUMBER:
455001614
ADMINISTRATOR:DEBORAH LARMOURFACILITY TYPE:
735
ADDRESS:2550 GALAXY WAYTELEPHONE:
(530) 605-3033
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 4CENSUS: 3DATE:
05/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:49 AM
MET WITH:Facility Manager: Will Tunget TIME COMPLETED:
11:50 AM
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On 05/16/2023, Licensing Program Analysts (LPA) Ivan Avila, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Manager, Will Tunget and explained the purpose of the visit. LPA ensured he used hand sanitizer shortly after entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA Avila and Will Tunget toured the facility together to ensure health and safety of clients in care. Areas toured include but are not limited to: common areas, resident bedrooms, garage, backyard, and the common restroom. LPA observed the facility to be clean, in good repair and odor-free and bathroom to have paper towels, trash can with lids and 20-second hand-washing poster. Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Hot water temperature was measured at 103 F. LPA observed two (2) fire extinguishers, fire detectors, and carbon monoxide detectors. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of two (2) client files. Facility has waiver for staff files to be located off-site. LPA reviewed one (1) client's P&I funds and one (1) client's daily medication log. No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report left at the facility.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2023
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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